# **HESI RN Exit Exam Version 4 | Questions, Answers
& Rationales**
---
**Question 1**
A nurse is assessing a client who is postoperative following a thyroidectomy. The client reports tingling
around the mouth and in the fingertips. Which of the following actions should the nurse take first?
A. Administer oral calcium supplements
B. Check the client's Chvostek's sign
C. Notify the healthcare provider
D. Place the client in Trendelenburg position
💫RATIONALE✔️✔️: Tingling indicates hypocalcemia from accidental parathyroid injury or removal.
Checking Chvostek's sign (facial twitching with tap over facial nerve) confirms neuromuscular irritability
before notifying the provider.
💫ANSWER✔️✔️: B. Check the client's Chvostek's sign
---
**Question 2**
A nurse is caring for a client with a prescription for furosemide 40 mg IV push. Which of the following
laboratory values should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
💫RATIONALE✔️✔️: Furosemide is a loop diuretic that causes significant potassium wasting, leading to
hypokalemia which increases risk of cardiac dysrhythmias and digoxin toxicity.
,💫ANSWER✔️✔️: B. Serum potassium
---
**Question 3**
A nurse is providing discharge teaching to a client with a new prescription for phenytoin. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will take my medication with antacids to prevent stomach upset"
B. "I will notify my dentist that I am taking this medication"
C. "I can stop this medication when my seizures stop"
D. "I will take this medication at bedtime only"
💫RATIONALE✔️✔️: Phenytoin causes gingival hyperplasia; good oral hygiene and dental monitoring are
essential. Antacids decrease absorption; medication is taken consistently, not only at bedtime; and
stopping abruptly can precipitate seizures.
💫ANSWER✔️✔️: B. "I will notify my dentist that I am taking this medication"
---
**Question 4**
A nurse is assessing a client who has a potassium level of 6.8 mEq/L. Which of the following ECG changes
should the nurse expect?
A. Flattened T waves
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged PR interval
💫RATIONALE✔️✔️: Hyperkalemia (normal 3.5-5.0 mEq/L) causes tall, peaked T waves, widened QRS, and
prolonged PR interval. Flattened T waves and U waves indicate hypokalemia.
💫ANSWER✔️✔️: C. Tall, peaked T waves
,---
**Question 5**
A nurse is caring for a client who is 1 hour postpartum and has a boggy uterus displaced to the right.
Which of the following actions should the nurse take?
A. Massage the fundus and assist the client to void
B. Administer oxytocin as prescribed
C. Apply a cold pack to the lower abdomen
D. Notify the healthcare provider immediately
💫RATIONALE✔️✔️: A boggy, displaced fundus suggests a distended bladder preventing uterine
contraction. The nurse should massage the fundus to firm it, then assist the client to void to allow the
uterus to contract effectively.
💫ANSWER✔️✔️: A. Massage the fundus and assist the client to void
---
**Question 6**
A nurse is providing teaching to a client with chronic kidney disease who is starting a low-phosphorus
diet. Which of the following food choices by the client indicates an understanding of the teaching?
A. Milk and cheese
B. Nuts and seeds
C. Fresh apple slices
D. Chocolate candy
💫RATIONALE✔️✔️: Fresh apples are low in phosphorus. Dairy products, nuts, seeds, and chocolate are
high-phosphorus foods that should be limited in CKD to prevent hyperphosphatemia and renal
osteodystrophy.
💫ANSWER✔️✔️: C. Fresh apple slices
, ---
**Question 7**
A nurse is assessing a client who is receiving a continuous heparin infusion for deep vein thrombosis.
The client's aPTT is 110 seconds (therapeutic range 60-80 seconds). Which of the following actions
should the nurse take?
A. Increase the infusion rate
B. Decrease the infusion rate
C. Stop the infusion and notify the provider
D. Continue the infusion as ordered
💫RATIONALE✔️✔️: An aPTT of 110 seconds indicates excessive anticoagulation and increased bleeding
risk. The nurse should stop the infusion and notify the provider for possible protamine sulfate
administration.
💫ANSWER✔️✔️: C. Stop the infusion and notify the provider
---
**Question 8**
A nurse is caring for a client with major depressive disorder who has been prescribed phenelzine, a
monoamine oxidase inhibitor (MAOI). Which of the following client statements indicates a need for
further teaching?
A. "I will avoid eating aged cheese and pepperoni"
B. "I need to check my blood pressure regularly"
C. "I can drink red wine with dinner occasionally"
D. "I will report severe headaches to my provider immediately"
💫RATIONALE✔️✔️: Red wine contains tyramine and can cause hypertensive crisis when combined with
MAOIs. Clients must avoid all tyramine-rich foods including aged cheese, cured meats, fermented
products, and alcohol.
💫ANSWER✔️✔️: C. "I can drink red wine with dinner occasionally"
& Rationales**
---
**Question 1**
A nurse is assessing a client who is postoperative following a thyroidectomy. The client reports tingling
around the mouth and in the fingertips. Which of the following actions should the nurse take first?
A. Administer oral calcium supplements
B. Check the client's Chvostek's sign
C. Notify the healthcare provider
D. Place the client in Trendelenburg position
💫RATIONALE✔️✔️: Tingling indicates hypocalcemia from accidental parathyroid injury or removal.
Checking Chvostek's sign (facial twitching with tap over facial nerve) confirms neuromuscular irritability
before notifying the provider.
💫ANSWER✔️✔️: B. Check the client's Chvostek's sign
---
**Question 2**
A nurse is caring for a client with a prescription for furosemide 40 mg IV push. Which of the following
laboratory values should the nurse monitor most closely?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
💫RATIONALE✔️✔️: Furosemide is a loop diuretic that causes significant potassium wasting, leading to
hypokalemia which increases risk of cardiac dysrhythmias and digoxin toxicity.
,💫ANSWER✔️✔️: B. Serum potassium
---
**Question 3**
A nurse is providing discharge teaching to a client with a new prescription for phenytoin. Which of the
following statements by the client indicates an understanding of the teaching?
A. "I will take my medication with antacids to prevent stomach upset"
B. "I will notify my dentist that I am taking this medication"
C. "I can stop this medication when my seizures stop"
D. "I will take this medication at bedtime only"
💫RATIONALE✔️✔️: Phenytoin causes gingival hyperplasia; good oral hygiene and dental monitoring are
essential. Antacids decrease absorption; medication is taken consistently, not only at bedtime; and
stopping abruptly can precipitate seizures.
💫ANSWER✔️✔️: B. "I will notify my dentist that I am taking this medication"
---
**Question 4**
A nurse is assessing a client who has a potassium level of 6.8 mEq/L. Which of the following ECG changes
should the nurse expect?
A. Flattened T waves
B. Prominent U waves
C. Tall, peaked T waves
D. Prolonged PR interval
💫RATIONALE✔️✔️: Hyperkalemia (normal 3.5-5.0 mEq/L) causes tall, peaked T waves, widened QRS, and
prolonged PR interval. Flattened T waves and U waves indicate hypokalemia.
💫ANSWER✔️✔️: C. Tall, peaked T waves
,---
**Question 5**
A nurse is caring for a client who is 1 hour postpartum and has a boggy uterus displaced to the right.
Which of the following actions should the nurse take?
A. Massage the fundus and assist the client to void
B. Administer oxytocin as prescribed
C. Apply a cold pack to the lower abdomen
D. Notify the healthcare provider immediately
💫RATIONALE✔️✔️: A boggy, displaced fundus suggests a distended bladder preventing uterine
contraction. The nurse should massage the fundus to firm it, then assist the client to void to allow the
uterus to contract effectively.
💫ANSWER✔️✔️: A. Massage the fundus and assist the client to void
---
**Question 6**
A nurse is providing teaching to a client with chronic kidney disease who is starting a low-phosphorus
diet. Which of the following food choices by the client indicates an understanding of the teaching?
A. Milk and cheese
B. Nuts and seeds
C. Fresh apple slices
D. Chocolate candy
💫RATIONALE✔️✔️: Fresh apples are low in phosphorus. Dairy products, nuts, seeds, and chocolate are
high-phosphorus foods that should be limited in CKD to prevent hyperphosphatemia and renal
osteodystrophy.
💫ANSWER✔️✔️: C. Fresh apple slices
, ---
**Question 7**
A nurse is assessing a client who is receiving a continuous heparin infusion for deep vein thrombosis.
The client's aPTT is 110 seconds (therapeutic range 60-80 seconds). Which of the following actions
should the nurse take?
A. Increase the infusion rate
B. Decrease the infusion rate
C. Stop the infusion and notify the provider
D. Continue the infusion as ordered
💫RATIONALE✔️✔️: An aPTT of 110 seconds indicates excessive anticoagulation and increased bleeding
risk. The nurse should stop the infusion and notify the provider for possible protamine sulfate
administration.
💫ANSWER✔️✔️: C. Stop the infusion and notify the provider
---
**Question 8**
A nurse is caring for a client with major depressive disorder who has been prescribed phenelzine, a
monoamine oxidase inhibitor (MAOI). Which of the following client statements indicates a need for
further teaching?
A. "I will avoid eating aged cheese and pepperoni"
B. "I need to check my blood pressure regularly"
C. "I can drink red wine with dinner occasionally"
D. "I will report severe headaches to my provider immediately"
💫RATIONALE✔️✔️: Red wine contains tyramine and can cause hypertensive crisis when combined with
MAOIs. Clients must avoid all tyramine-rich foods including aged cheese, cured meats, fermented
products, and alcohol.
💫ANSWER✔️✔️: C. "I can drink red wine with dinner occasionally"
