# **HESI RN Exit Exam Version 5 |
Questions, Answers & Rationales**
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**Question 1**
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following findings
requires immediate intervention?
A. Continuous bubbling in the suction control chamber
B. Tidaling in the water seal chamber with respirations
C. Drainage of 50 mL of serosanguineous fluid in the past hour
D. Sudden cessation of tidaling in the water seal chamber
💫ANSWER✔️✔️: D. Sudden cessation of tidaling in the water seal chamber
💫RATIONALE✔️✔️: Sudden cessation of tidaling indicates possible obstruction, kinking, or clamping of
the tube, which can lead to tension pneumothorax.
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**Question 2**
A nurse is assessing a client who is receiving a continuous enteral tube feeding. Which of the following
findings should the nurse report to the provider immediately?
A. Gastric residual volume of 150 mL
B. Blood glucose level of 140 mg/dL
C. New onset of abdominal distension
D. Diarrhea for the past 24 hours
💫ANSWER✔️✔️: C. New onset of abdominal distension
,💫RATIONALE✔️✔️: Abdominal distension indicates possible tube feeding intolerance or ileus, which can
precede vomiting and aspiration.
---
**Question 3**
A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the
following instructions should the nurse include?
A. "Take your pulse for 30 seconds before taking the medication."
B. "Repeat the dose if you vomit within 30 minutes of taking it."
C. "Double the next dose if you miss one dose."
D. "Avoid taking this medication with high-fiber foods."
💫ANSWER✔️✔️: D. "Avoid taking this medication with high-fiber foods."
💫RATIONALE✔️✔️: High-fiber foods bind with digoxin and reduce absorption; the pulse should be taken
for 60 seconds, and missed doses should never be doubled.
---
**Question 4**
A nurse is assessing a client who is 6 hours postpartum. The client reports a large gush of blood and the
nurse notes a saturated perineal pad. The fundus is firm and at the umbilicus. Which of the following
actions should the nurse take?
A. Massage the fundus vigorously
B. Increase the IV oxytocin rate
C. Assess for perineal lacerations or hematoma
D. Notify the provider immediately
💫ANSWER✔️✔️: C. Assess for perineal lacerations or hematoma
💫RATIONALE✔️✔️: A firm fundus with heavy bleeding suggests lower genital tract trauma (lacerations,
hematoma) rather than uterine atony.
,---
**Question 5**
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and is prescribed
metformin. Which of the following should the nurse include in the teaching plan?
A. "Take this medication with food to prevent gastrointestinal upset."
B. "Monitor for signs of hypoglycemia within 1 hour of taking the dose."
C. "You may stop taking this medication when your blood sugar is normal."
D. "This medication increases insulin production from your pancreas."
💫ANSWER✔️✔️: A. "Take this medication with food to prevent gastrointestinal upset."
💫RATIONALE✔️✔️: Metformin causes GI distress; taking with meals reduces this. It decreases hepatic
glucose production, not insulin secretion.
---
**Question 6**
A nurse is assessing a client who is receiving IV vancomycin. The client reports a rash on the chest and
neck. Which of the following actions should the nurse take first?
A. Administer diphenhydramine as prescribed
B. Slow the rate of the vancomycin infusion
C. Stop the vancomycin infusion immediately
D. Document the finding as an expected reaction
💫ANSWER✔️✔️: C. Stop the vancomycin infusion immediately
💫RATIONALE✔️✔️: Rash may indicate an allergic reaction or red man syndrome; stopping the infusion is
the priority to prevent anaphylaxis.
---
, **Question 7**
A nurse is providing care for a client with active pulmonary tuberculosis. Which of the following
precautions should the nurse implement?
A. Contact precautions with private room
B. Airborne precautions with negative pressure room
C. Droplet precautions with face shield
D. Standard precautions only with mask
💫ANSWER✔️✔️: B. Airborne precautions with negative pressure room
💫RATIONALE✔️✔️: TB is transmitted via airborne droplet nuclei; N95 respirator and negative pressure
room are required.
---
**Question 8**
A nurse is assessing a client who has a potassium level of 2.9 mEq/L. Which of the following ECG changes
should the nurse expect?
A. Tall, peaked T waves
B. ST segment elevation
C. Prominent U waves
D. Widened QRS complex
💫ANSWER✔️✔️: C. Prominent U waves
💫RATIONALE✔️✔️: Hypokalemia causes U waves, flat T waves, and ST depression; tall T waves are seen
in hyperkalemia.
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**Question 9**
Questions, Answers & Rationales**
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**Question 1**
A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following findings
requires immediate intervention?
A. Continuous bubbling in the suction control chamber
B. Tidaling in the water seal chamber with respirations
C. Drainage of 50 mL of serosanguineous fluid in the past hour
D. Sudden cessation of tidaling in the water seal chamber
💫ANSWER✔️✔️: D. Sudden cessation of tidaling in the water seal chamber
💫RATIONALE✔️✔️: Sudden cessation of tidaling indicates possible obstruction, kinking, or clamping of
the tube, which can lead to tension pneumothorax.
---
**Question 2**
A nurse is assessing a client who is receiving a continuous enteral tube feeding. Which of the following
findings should the nurse report to the provider immediately?
A. Gastric residual volume of 150 mL
B. Blood glucose level of 140 mg/dL
C. New onset of abdominal distension
D. Diarrhea for the past 24 hours
💫ANSWER✔️✔️: C. New onset of abdominal distension
,💫RATIONALE✔️✔️: Abdominal distension indicates possible tube feeding intolerance or ileus, which can
precede vomiting and aspiration.
---
**Question 3**
A nurse is providing discharge teaching to a client who has a new prescription for digoxin. Which of the
following instructions should the nurse include?
A. "Take your pulse for 30 seconds before taking the medication."
B. "Repeat the dose if you vomit within 30 minutes of taking it."
C. "Double the next dose if you miss one dose."
D. "Avoid taking this medication with high-fiber foods."
💫ANSWER✔️✔️: D. "Avoid taking this medication with high-fiber foods."
💫RATIONALE✔️✔️: High-fiber foods bind with digoxin and reduce absorption; the pulse should be taken
for 60 seconds, and missed doses should never be doubled.
---
**Question 4**
A nurse is assessing a client who is 6 hours postpartum. The client reports a large gush of blood and the
nurse notes a saturated perineal pad. The fundus is firm and at the umbilicus. Which of the following
actions should the nurse take?
A. Massage the fundus vigorously
B. Increase the IV oxytocin rate
C. Assess for perineal lacerations or hematoma
D. Notify the provider immediately
💫ANSWER✔️✔️: C. Assess for perineal lacerations or hematoma
💫RATIONALE✔️✔️: A firm fundus with heavy bleeding suggests lower genital tract trauma (lacerations,
hematoma) rather than uterine atony.
,---
**Question 5**
A nurse is caring for a client who has a new diagnosis of type 2 diabetes mellitus and is prescribed
metformin. Which of the following should the nurse include in the teaching plan?
A. "Take this medication with food to prevent gastrointestinal upset."
B. "Monitor for signs of hypoglycemia within 1 hour of taking the dose."
C. "You may stop taking this medication when your blood sugar is normal."
D. "This medication increases insulin production from your pancreas."
💫ANSWER✔️✔️: A. "Take this medication with food to prevent gastrointestinal upset."
💫RATIONALE✔️✔️: Metformin causes GI distress; taking with meals reduces this. It decreases hepatic
glucose production, not insulin secretion.
---
**Question 6**
A nurse is assessing a client who is receiving IV vancomycin. The client reports a rash on the chest and
neck. Which of the following actions should the nurse take first?
A. Administer diphenhydramine as prescribed
B. Slow the rate of the vancomycin infusion
C. Stop the vancomycin infusion immediately
D. Document the finding as an expected reaction
💫ANSWER✔️✔️: C. Stop the vancomycin infusion immediately
💫RATIONALE✔️✔️: Rash may indicate an allergic reaction or red man syndrome; stopping the infusion is
the priority to prevent anaphylaxis.
---
, **Question 7**
A nurse is providing care for a client with active pulmonary tuberculosis. Which of the following
precautions should the nurse implement?
A. Contact precautions with private room
B. Airborne precautions with negative pressure room
C. Droplet precautions with face shield
D. Standard precautions only with mask
💫ANSWER✔️✔️: B. Airborne precautions with negative pressure room
💫RATIONALE✔️✔️: TB is transmitted via airborne droplet nuclei; N95 respirator and negative pressure
room are required.
---
**Question 8**
A nurse is assessing a client who has a potassium level of 2.9 mEq/L. Which of the following ECG changes
should the nurse expect?
A. Tall, peaked T waves
B. ST segment elevation
C. Prominent U waves
D. Widened QRS complex
💫ANSWER✔️✔️: C. Prominent U waves
💫RATIONALE✔️✔️: Hypokalemia causes U waves, flat T waves, and ST depression; tall T waves are seen
in hyperkalemia.
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**Question 9**
