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EXIT HESI EXAM 2025
A nurse is reviewing the laboratory results of a client who has rheumatoid arthritis. Which of the following findings should the nurse report to the provider? a. WBC count 8, b. platelets 150, c. aspartate aminotransferase 10 units d. erythrocyte sedimentation rate 75mm - ANSWER d A nurse is caring for a client who has generalized petechiae and ecchymoses. The nurse should expect a prescription for which of the following laboratory tests? a. platelet count b. potassium level c. creatine clearance d. prealbumin - ANSWER a A nurse is caring for a client following application of a cast. Which of the following actions should the nurse take first? a. place an ice pack over the cast b. palpate the pulse distal to the cast c. teach the client to keep the cast clean and dry d. position the casted extremity on a pillow - ANSWER b A nurse is caring for a client who has vision loss. Which of the following actions should the nurse take? SATA keep objects in the clients room in the same place. ensure there is high-wattage lighting in the clients room. c. approach the client from the side d. allow extra time for the client to perform tasks e. touch the client gently to announce presence - ANSWER a, b, d A nurse is caring for a client who is newly diagnosed with pancreatic cancer and has questions about the disease. To research the nurse should identify that which of the following electronic database has the most comprehensive collection nursing articles? a. medline b. C inahl c. ProQuest d. health source - ANSWER b A nurse in the emergency department is assessing newly admitted client who is experiencing drooling and hoarseness following a brain injury. Which of the following actions should the nurse take first? obtain a baseline EKG Obtain a blood specimen for ABG analysis c. insert an 18 gauge IV catheter d. Administer 100% humidified oxygen - ANSWER d
A nurse is planning care for a client who has unilateral paralysis and dysphagia following a right hemispheric stroke. Which of the following interventions should the nurse include in the plan? a. Place food on the left side of the client's mouth when he is ready to eat. b. Provide total care in performing the client's ADLs. c. Maintain the client on bed rest. d. Place the client's left arm on a pillow while he is sitting. - ANSWER d A nurse is caring for a client who is in a seclusion room following violent behavior. The client continues to display aggressive behavior. Which of the following actions should the nurse take? Confront the client about this behavior. Express sympathy for the client's situation. c. Speak assertively to the client. d. Stand within 30 cm (1 ft) of the client when speaking with them. - ANSWER a A nurse is caring for a client who is receiving brachytherapy for treatment of prostate cancer. Which of the following actions should the nurse take? a. Cleanse equipment before removal from the client's room. b. Limit the client's visitors to 30 min per day. c. Discard the client's linens in a double bag. d. Discard the radioactive source in a biohazard bag - ANSWER b A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate intravenously. The nurse discontinues the magnesium sulfate after the client displaces toxicity. Which of the following actions should the nurse take? Position the client supine Prepare an IV bolus of dextrose 5% in water c. Administer methylergonovine IM d. Administer calcium gluconate IV - ANSWER d A charge nurse is teaching new staff members about factors that increase a client's risk to become violent. Which of the following risk factors should the nurse include as the best predictor of future violence? a. Experiencing delusions b. Male gender c. Pervious violent behavior d. A history of being in prison - ANSWER c A nurse is preparing to perform a sterile dressing change. Which of the following actions should the nurse take when setting up the sterile field? Place the cap from the solution sterile side up on clean surface Open the outermost flap of the sterile kit toward the body→ flap AWAY from the body's first Place the sterile dressing within 1.25 cm (0.5in) of the edge of the sterile field → 2.5 cm (1-inch) border around any sterile drape or wrap that is considered contaminated.
d. Absent gag reflex→ possibly due to anesthesia given. (1 hour postoperative) - ANSWER a Rationale "Requires immediate action" choose the worst possibility that could lead to. ABC A nurse is planning care for a preschool-age child who is in the acute phase Kawasaki disease. Which of the following interventions should the nurse include in the plan of care? a. Give scheduled doses of acetaminophen every 6 hr b. Monitor the child's cardiac status c. Administer antibiotics via intermittent IV bolus for 24 hr d. Provide stimulation with children of the same age in the playroom - ANSWER b A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco? Use of tobacco might lead to alcohol and drug abuse Smoking in adolescence increases the risk of developing lung cancer later in life c. Use of tobacco decreases the level of athletic ability d. Smoking in adolescence increases the risk of lifelong addiction - ANSWER c A nurse is assessing a client who is prescribed spironolactone. Which of the following laboratory values should the nurse monitor for this client? a. Total bilirubin b. Urine ketones c. Serum potassium- diuretic that retains potassium= hyperkalemic risk d. Platelet count - ANSWER c A nurse has agreed to serve as an interpreter for an older adult client who is assigned to another nurse. Which of the following statements by the nurse indicates an understanding of this role? a. "I will let the client know that I am available as the interpreter." b. "I will receive a small fee for interpreting for this client." c. "I am glad I'm available today, but when I'm not, you can use a family member." d. "I will let the client know that an interpreter is unavailable during the night shift." - ANSWER a A nurse in a pediatric unit is preparing to insert an IV catheter for 7-year- old. Which of the following actions should the nurse take? Tell the child they will feel discomfort during the catheter insertion. Use a mummy restraint to hold the child during the catheter insertion. Require the parents to leave the room during the procedure. - ANSWER a A nurse is caring for a client who has arteriovenous fistula which of the following findings should the nurse report? Thrill upon palpation.
Absence of a bruit. Distended blood vessels Swishing sound upon auscultation - ANSWER b A nurse is providing discharge teaching for a client who has an implantable cardioverter defibrillator which of the following statements demonstrates understanding of the teaching? a. "I will soak in the tub rather and showering" b. "I will wear loose clothing around my ICD" c. "I will stop using my microwave oven at home because of my ICD" d. "I can hold my cellphone on the same side of my body as the ICD" - ANSWER b A nurse is caring for a client who is at 14 weeks gestation and reports feelings of ambivalence about being pregnant. Which of the following responses should the nurse make? "Describe your feelings to me about being pregnant" "You should discuss your feelings about being pregnant with your provider" c. "Have you discussed these feelings with your partner?" d. "When did you start having these feelings?" - ANSWER a A nurse is planning care for a client who has a prescription for a bowel- training program following a spinal cord injury. Which of the following actions should the nurse include in the plan of care? a. Encourage a maximum fluid intake of 1,500 ml per day. b. Increase the amount of refined grains in the client's diet. c. Provide the client with a cold drink prior to defecation. d. Administer a rectal suppository 30 minutes prior to scheduled defecation times. - ANSWER d A nurse is performing physical therapy for a client who has Parkinson's disease. Which of the following statements by the client indicates the need for a referral to physical therapy? a. "I have been experiencing more tremors in my left arm than before" b. "I noticed that I am having a harder time holding on to my toothbrush" c. " Lately, I feel like my feet are freezing up, as they are stuck to the ground" d. "Sometimes, I feel I am making a chewing motion when I'm not eating" - ANSWER c A nurse is reviewing laboratory data for a client who has chronic kidney disease. Which of the following findings should the nurse expect? Increased creatine. Increased hemoglobin. c. Increased bicarbonate. d. Increased calcium. - ANSWER a
d. Children who have varicella are contagious 4 days before the first vesicle eruption. - ANSWER a A nurse is reviewing the laboratory report of a client who has been having lithium carbonate for the past 12 months. The nurse notes a lithium level of 0.8 mEq/L. Which of the following orders from the provider should the nurse expect? a. Withhold the next dose. b. Increase the dosage. c. Discontinue the medication. d. Administer the medication. - ANSWER d A nurse is caring for a client who has fibromyalgia and requests pain medication. Which of the following medications should the nurse administer? a. Pregabalin b. Lorazepam c. Colchicin d. Codeine. - ANSWER a A nurse is caring who is to receive a transfusion of packed RBCs. Which of the following actions should the nurse take? a. Prime IV tubing with 0.9% sodium chloride. b. use a 24- gauge IV catheter c. obtain filter less IV tubing d. place blood in the warmer for 1 hr - ANSWER a A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following should the toddler participate? a. Looking at alphabet flashcards. b. Playing with a large plastic truck. c. Use scissors cut out paper shapes. d. Watching a cartoon in the dayroom. - ANSWER b A nurse is caring for a client who has chronic pancreatitis. Which of the following dietary recommendations should the nurse make? Coffee with creamer. Lettuce with sliced avocados. Broiled skinless chicken breast with brown rice. d. Warm toast with margarine. - ANSWER c A nurse is caring for a client who is in active labor and requests pain management. Which of the following actions should the nurse take? Administer ondansetron. Place the client in a warm shower. Apply fundal pressure during contractions. Assist the client to a supine position. - ANSWER b
A nurse in an emergency department is performing triage for multiple clients following a disaster in the community. To which of the following types of injuries should the nurse assign the highest priority? a. Below-the knee amputation b. Fractured tibia c. 95% full-thickness body burn d. 10cm (4in) laceration to the forearm - ANSWER a A nurse manager is updating protocols for the use of belt restraints. Which of the following guidelines should the nurse include? Remove the client's restraint every 4hr Document the client's condition every 15 min c. Attach the restrain to the bed's side rails d. Request a PRN restrain prescription for clients who are aggressive - ANSWER b A nurse is teaching an in-service about nursing leadership. Which of the following information should the nurse include about an effective leader? a. Acts as an advocate for the nursing unit. c. Priorities staff request over client needs. d. Provides routine client care and documentation. - ANSWER a A nurse is reviewing the laboratory findings of a client who has diabetes mellitus and reports that she has been following her care. The nurse should identify which of the following findings indicates a need to revise the client's plan of care. a. Serum sodium 144 mEq/ b. Hba1c 10 % c. Random serum glucose 190 mg/dl. - ANSWER b A nurse is caring for a client who is at 38 weeks of gestation and has a history of hepatitis C. The client asks the nurse if she will be able to breastfeed. Which of the following responses by the nurse is appropriate? a. You may breastfeed unless your nipples are cracked or bleeding b. You must use a breast pump to provide breast milk. c. You must use nipple shield when breastfeeding. d. You may breastfeed after your baby develops his antibiotics. - ANSWER a A nurse is caring for a client who has returned to the medical-surgical unit following a transurethral resection of the prostate. Which of the following should the nurse identify as priority nursing assessment after reviewing the clients information? Exhibit. loss of consciousness. (priority)- decreased LOC can mean less o2 going to the brain. Skin turgor deep tendon reflexes Bowel sounds - ANSWER a
A nurse is caring for a client who will undergo a procedure. The client states he does not want the provider to discuss the results with his partner. Which of the following is an appropriate response for the nurse to make? You have the right to decide who receives information Your partner can be a great source of support for you at this time Is there a reason you don't want your partner to know about your procedure? d. The provider will be tactful when talking to your partner - ANSWER a A nurse is discussing a weight loss with a client who is concerned about losing 6.8 kg (15lb) from an original weight of 9o.7 (200 lb). The nurse should identify the weight of the following total percentage? a. 7.5% b. 15% c. 8.1% 13.3% - ANSWER a A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? Perform fundal massage (massage if fundus is boggy) Pour water from a squeeze bottle over the patients perineal area. c. Insert an indwelling urinary catheter. d. Apply cold therapy to the client's perineal area.( warm) - ANSWER b A nurse is providing discharge teaching to a client who has cancer and a prescription for a fentanyl 25 mcg /hr transdermal patch. Which of the following instructions should the nurse include in the teaching? a. Avoid hot tub while wearing the patch b. Apply patch to your forearm c. Avoid high-fiber foods while taking this medication d. Remove the patch for 8 hours every day to reduce the risk for tolerance. - ANSWER a A nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? We should discuss resources to implement in your daily life Let me show you simple relaxation exercises to manage stress. c. Let's talk about how you can change your response to stress d. We should establish our roles in the initial session. - ANSWER d A nurse is providing discharge teaching to a client who has a new prescription for phenelzine. The nurse should instruct the client that it is safe to eat which of the following foods while taking this medication? Avocados Whole grain bread
Pepperoni pizza Smoked salmon - ANSWER b A nurse is receiving a change-of-shift report for an adult female client who is postoperative. Which of the following client information should the nurse report? - ANSWER Lower platelets A nurse manager is developing a protocol for an urgent care clinic that often cares for clients who do not speak the same language as clinical staff. Which of the following instructions should the nurse include? A. Use the client's children to provide interpretation. B. The nurse was going to do the interpretation C. Offer client's translation services for a nominal fee. D. Evaluate the clients' understanding at regular intervals - ANSWER b A hospice nurse is visiting with the son of a client who has terminal cancer. The son reports sleeping very little during the past week due to caring for his mother. Which of the following responses should the nurse make? a. "I can give you information about respite care if you are interested." b. "You should consider taking a sleeping pill before bed each night" c. "It must be difficult taking care of someone who is terminally ill" d, "You are doing a great job taking care of your mother" - ANSWER a A nurse is assessing a child who is being treated for bacterial pneumonia. The nurse notes an increase in the child's glucose. The nurse should identify this finding as an adverse effect of which of the following medications a. Methylprednisolone. b. Ondansetron. c. Guaifenesin. d. Amoxicillin - ANSWER a The nurse is providing teaching about folic acid to a client who is prima gravida. Which of the following information should the nurse include in the teaching? a. "You should take folic acid to decrease the risk of transmitting infections to your baby" b. "You should consume a maximum of 300 micrograms of folic acid every day". c. "You can increase your dietary intake of folic acid by eating cereals and citrus fruits". d. "You can expect your urine to appear red-tingled while taking folic acid supplements".
- ANSWER c A community health nurse is assessing an adolescent who is pregnant. Which of the following assessments is the nurse's priority? Social relationship with peers. Plans for attending school while pregnant. c. Medicaid? d. Understanding of infant care. - ANSWER c
A nurse in a mental health unit is planning room assignments for four clients. Which of the following client should be closest to the nurse's station? a. A client who has an anxiety disorder and is experiencing moderate anxiety. b. A client who has somatic symptom disorder and reports chronic pain. c. A client who has depressive disorder and reports feeling hopeless. d. A client who has bipolar disorder and impaired social interactions. - ANSWER c A nurse is planning care for a client who has bipolar disorder and is experiencing mania. Which of the following interventions should the nurse include in the plan? Encourage the client to spend time in the day room Withdraw the client's TV privileges is the does not attend group therapy c. Encourage the client to take frequent rest periods d. Place the cline in seclusion when he exhibits signs of anxiety - ANSWER c A nurse is admitting medications to a group of clients. Which of the following occurrences requires the completion of an incident report? A client receives his antibiotics 2hr late A client vomits within 20min of taking his morning medications c. A client requests his statin to be administered at 2100 d. A client asks for pain medication 1hr early - ANSWER a A nurse is caring for a client who is 24 hr. postpartum and is breast feeding her newborns. The client asks the nurse to warm up seaweed soup that the client's partner brought for her. Which of the following responses should the nurse make? a. "Does the doctor know you are eating that?" b. "Why are you eating seaweed soup?" c. "Of course I will heat that up for you" d. "The hospital good is more nutritious" - ANSWER a A nurse is preparing an in-service for a group of nurses about malpractice issues in nursing. Which of the following examples should the nurse include in the teaching? a. Leaving a nasogastric tube clamped after administering oral medication Documenting communication with a provider in the progress notes of the client's medical records Administering potassium via IV bolus Placing a yellow bracelet on a client who is at risk for falls - ANSWER c A nurse is providing teaching to family members of a client who has dementia. Which of the following instructions should the nurse include in the teaching? a. Establish a toileting schedule for the client b. Use clothing with buttons and sippers c. Discourage physical activity during the day d. Engage the client in activities that increase sensory stimulation - ANSWER a
The nurse is reviewing the medical record of a client who is requesting combination oral contraceptives. Which of the following conditions in the client's history is a contradiction to the use of oral contraceptives? a. Hyperthyroidism. b. Thrombophlebitis. c. Diverticulosis. d. Hypocalcemia. - ANSWER b A nurse is admitting a client who has schizophrenia and experiences auditory hallucinations. The client states, "It's hard not to listen to the voices." Which of the following questions should the nurse ask the client? a. "Do you understand that the voices are not real?" b. "Why do you think the voices are talking to you?" c. "Have you tried going to a private place when this occurs?" d. "What helps you ignore what you are hearing?" - ANSWER d A charge nurse is teaching a group of newly licensed nurses about the correct use of restraints. Which of the following should the nurse include in the teaching? a. Placing a belt restraint on a school-age child who has seizures. b. Securing wrist restraints to the bed rails for an adolescent. c. Applying elbow immobilizers of an infant receiving cleft lip injury d. Keeping the side rails of a toddler's crib elevated. - ANSWER c A nurse is preparing to mix NPH and regular insulin in the same syringe. Which of the following Inject air into the NPH insulin vial. Withdraw the prescribed dose of regular insulin Withdraw the prescribed dose of NPH insulin - ANSWER a A Nurse is working with a client who has an anxiety disorder and is in the orientation phase of the therapeutic relationship. Which of the following statements should the nurse make during this phase? a. "Let's talk about how you can change your response to stress." b. "We should establish our roles in the initial session." c.. "Let me show you simple relaxation exercises to manage stress." d. "We should discuss resources to implement in your daily life." - ANSWER b A nurse is caring for a client who is 4 hr postpartum and reports that she cannot urinate. Which of the following interventions should the nurse implement? Perform fundal massage ( massage if fundus is boggy) Pour water from a squeeze bottle over the client's perineal area. d. Insert an indwelling urinary catheter. e. Apply cold therapy to the client's perineal area.( warm) - ANSWER b
Polydipsia = hyperglycemia c. Acetone Breath odor = DKA d. Diaphoresis - ANSWER a, d A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding? a. Upper extremity hypotension b. Increased intracranial pressure c. Frequent nosebleeds d. Weak femoral pulses - ANSWER d A community health nurse is planning primary prevention activities to reduce the occurrence of abuse. Which of the following strategies should the nurse include in the plan? Instruct healthcare professionals to identify abusive situations (screening=secondary prevention) Locate financial support to open a shelter for abuse survivors (3rd) c. Teach parenting skills to families at risk for abuse d. Connect abuse survivors with legal counsel (3rd) - ANSWER c A nurse and an assistive personnel (AP) are caring for a group of clients. Which of the following tasks is appropriate for the nurse to delegate to the AP? a. Documenting the report of pain for a client who is postoperative b. Administering oral fluids to a client who has dysphagia- c. Applying a condom catheter for a client who has a spinal cord injury. d. Reviewing active range-of-motion exercise with a client who had a stroke - ANSWER A nurse is providing teaching to an adolescent who has peptic ulcer disease. Which of the following statements by the client indicates an understanding of the teaching? a. "I will take sucralfate with meals three times per day" b. "I will avoid food and beverages that contain caffeine" c. "I will decrease my daily protein intake to 15 grams per day" d. "I will use ibuprofen as needed to control abdominal pain" - ANSWER b A nurse is caring for a client who reports xerostomia following radiation therapy to the mandible. Which of the following is an appropriate action by the nurse? Offer the client saltine crackers between meals Suggest rinsing his mouth with an alcohol-based mouthwash c. Provide humidification of the room air d. Instruct the client on the use of esophageal speech - ANSWER c A nurse is caring for four clients. Which of the following tasks can the nurse delegate to an assistive personnel? Assess effectiveness of antiemetic medication- Perform chest compressions during cardiac resuscitation- c. Perform a dressing change for a new amputee-
d. Apply a transdermal nicotine patch- - ANSWER b A nurse is caring for a client who states he recently purchased lavender oil to use when he gets the flu. The nurse should recognize which of the following findings as a potential contraindication for using lavender? The client takes vitamin C daily The client has a history of alcohol use disorder c. The client has a history of asthma d. The client takes furosemide twice daily - ANSWER c A nurse is caring for a client who has major depressive disorder and a new prescription for amitriptyline. The nurse should monitor for which of the following adverse effects? a. Increased salivation- dry it will cause - anticholinergic effects Weight loss Urinary retention Hypertension- orthostatic hypotension it will cause instead - ANSWER c A nurse is conducting a health promotion class about the use of oral contraceptives. Which of the following disorders is a contraindication for oral contraceptive use? Asthma Hypertension c. Fibromyalgia d. Fibrocystic breast condition - ANSWER b A nurse is providing teaching to a client who will undergo a magnetic resonance imaging (MRI) scan. Which of the following statements is appropriate to include in the teaching? a. "You should not have this procedure if you are allergic to iodine." b. "You should not have this procedure if you have a tattoo." c. "The nurse will ask you to wear protective eyewear during this procedure." d. "The nurse will ask you to remove any transdermal patches prior to the procedure." - ANSWER a A nurse in a provider's office is reviewing a female client's medical record during a routine visit. The nurse should recommend increasing dietary intake of which of the following vitamins? (Exhibit) --only tab shown is Tab 3: H&P: postmenopausal, hx DVT and iron deficiency anemia, works indoors, consumes 1-2 alcoholic beverages per week a. Vitamin D b. Vitamin K c. Vitamin A d. Vitamin B12 - ANSWER d
A nurse is preparing to reposition a client who had a stroke. Which of the following actions should the nurse take? a. Raise the side rails on both sides of the client's bed during repositioning. b. Reposition the client without assistive devices. c. Discuss the client's preferences for determining a reposition schedule. d. Evaluate the client's ability to help with repositioning. - ANSWER d A nurse is caring for an infant who has coaction of the aorta. Which of the following should the nurse identify as an expected finding? a. Weak femoral pulses b. Frequent nosebleeds c. Upper extremity hypotension d. Increased intracranial pressure - ANSWER a A nurse is assisting with the development of an informed document for participation in a research study. Which of the following information should the nurse include? A statement that participants can leave the study at will. An assignment of the participant to either the experimental or control group. c. A list of the clients participating in the study. d. A description of the framework the researchers will use to evaluate the data. - ANSWER a A nurse is providing teaching to a client about the adverse effects of sertraline. Which of the following adverse effects should the nurse include? Excessive sweating Increased urinary frequency c. Dry cough d. Metallic taste in mouth - ANSWER a A nurse is caring for a client who has a new temporary synchronous pacemaker. Which of the following should the nurse report to the provider? a. The client's pulse oximetry level is 96%. b. The client develops hiccups. c. The ECG shows pacing spikes after the QRS complex. - ANSWER b A nurse is preparing discharge information for a client who has type 2 diabetes mellitus. Which of the following resources should the nurse provide to the client? a. Personal blogs about managing the adverse effects of diabetes medications b. Food label recommendations from the Institute of Medicine c. Diabetes medication information from the Physicians' Desk Reference d. Food exchange lists for meal planning from the American Diabetes Association - ANSWER d A nurse is providing teaching about patient-controlled analgesia (PCA) to a client. Which of the following statements should the nurse include in the teaching? "The PCA will deliver a double dose of medication when you push the button twice."
"You can adjust the amount of pain medication you receive by pushing on the keypad." "Continuous PCA infusion is designed to allow fluctuating plasma medication levels." d. "You should push the button before physical activity to allow maximum pain control." - ANSWER d A nurse is caring for a client who has diabetes mellitus and is receiving long-acting insulin for blood glucose management. The nurse should anticipate administering which of the following types of insulin? a. Glargine insulin. b. Regular insulin. c. NPH insulin. - ANSWER a A nurse is caring for a client who is receiving intermittent feedings via a feeding via a feeding pump and is experiencing dumping syndrome. Which of the following actions should the nurse take? Administer a refrigerated feeding. Increased the amount of water use to flush the tubing. c. Rate of the client's feedings. d. Instruct the client to move onto their right side. - ANSWER c A nurse in an emergency department is caring for a client who received a dose of penicillin and is now anxious, flushing, tachycardic and has difficulty swallowing. Which of the following actions is the nurse's priority? a. Monitor the client's ECG b. Take the client's vital signs. c. Administer oxygen d. Insert an IV line. - ANSWER c A nurse is caring for a client who has Raynaud's disease. Which of the following actions should the nurse take? a. Provide information about stress management. b. Maintain a cool temperature in the client's room. c. Administer epinephrine for acute episodes. d. Give glucocorticoid steroid twice per day. - ANSWER a A nurse is reviewing the medical history of a client who has angina. Which of the following findings in the client's medical history should identify as a risk factor for angina? a. Hyperlipidemia. b. COPD c. Seizure disorder d. Hyponatremia. - ANSWER a
