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HESI EXIT V2 EXAM
with NGN Questions and Rationalized Answers,
100% VERIFIED NEWEST VERSION.
The exam has: 160 Multiple-choice questions
Performance Score is Above 1100
1. When preparing to administer a prescribed medication to a homeless client
at a community psychiatric clinic. The client tells the nurse that the usual
dosage taken is different from the dose the nurse is giving. Which action
should the nurse take?
A) Inform the client that he may refuse the medication and document whether
or not the client takes it.
B) Withhold the medication until the dosage can be confirmed.
C) Explain to the client that the dosage has been changed.
D) Tell the client to take the medication then verify the dosage at the next
healthcare team meeting
Ans>> B) Withhold the medication until the dosage can be confirmed.
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2. The charge nurse is making assignments for one practical nurse and three
registered nurses who are caring for neurologically compromised clients.
Which client with which change in status is best to assign to the PN?
A) Subdural hematoma whose blood pressure changed from 150/80 to 170/60.
B) Viral meningitis whose temperature change from 101 S to 102F.
C) Diabetic keto acidosis who is Glasgow coma scale score changed from 10
to 7.
D) Myxedema, whose blood pressure change from 80/50 to 70/40
Ans>> B) Viral meningitis whose temperature change from 101 S to 102F.
3. The nurse is caring for a client with pneumonia who now develops initial
signs of septic shock and multi organ failure. The healthcare provider prescribes a sepsis protocol. Which intervention is most important for the nurse
to include in the plan of care?
A) Maintain strict intake and output.
B) Keep head of bed raised 45°.
C) Excess warmth of extremities.
D) Monitor blood glucose level
Ans>> A) Maintain strict intake and output.
4. And adolescent client is admitted to the hospital because of writing a
suicide note to a teacher at school. On the second day of hospitalization, the
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nurse asked the client to meet with the treatment team. After the team meeting,
the client leaves in tears and goes to their room. Which nursing intervention
is best?
A) Let the client rest quietly in their room for a while.
B) Explore the clients goals and desire for treatment.
C) Ask the treatment team about the clients behavior.
D) Go to the clients room and ask what happened
Ans>> D) Go to the clients room and ask what happened.
5. The healthcare provider prescribes dalteparin 200 units per kilogram subcutaneous once a day for a client who weighs 154 pounds. The medication is
available and 25,000 units per milliliter vial. How many milliliters should the
nurse administer? (Enter numerical value only. If rounding is required, round
to the nearest 10th.): 0.6
6. NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency
department last night when he was having more difficulty breathing he has a
history of 1/2 pack a day cigarette smoking for 20 years. He has no significant
medical or surgical history.
Which two orders should the nurse complete first?
A) Sputum culture.
B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
D) Chest x-ray.
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E) Acetominophen 350 mg PO every six hours for temperature control.
F) Run 0.9% sodium chloride IV infusion at 150 mL per hour.
G) Start peripheral IV.
H) NPO
Ans>> B) Start oxygen 3 L per minute via nasal cannula.
C) Place the client on a cardio respiratory monitor.
7. NGN: 0330: place the client on a cardio respiratory monitor, NPO, sputum
culture, start a peripheral IV infusion, start oxygen 3 L per minute via nasal
cannula, begin 0.9% sodium chloride IV infusion at 150 mL per hour, acetaminophen 350 mg PO every six hours for temperature.
To start the client on oxygen as ordered which items should the nurse collects
from the supply room? SATA
A) humidifier bottle.
B)Suction canister.
C)Sterile water.
D) Nasal cannula.
E) Flow meter.
F) Lambs wool.
G) Tape
Ans>> D) Nasal cannula.
) Flow meter.
8. NGN: states, I am feeling extremely anxious right now. The client has decreased breath sounds in the left lower low. His mucus membranes are dry.
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He has a productive cough with thick, yellow secretions. His capillary refill is
four seconds. Vital signs, temperature 100.2. Heart rate 101 bpm, respiratory
rate 28 breaths per minute, blood pressure 145/89, oxygen saturation 90% on
room air.
(for each body system click to specify the assessment findings that indicates
hypoxia)
Cardiovascular: heart rate 100 bpm, capillary refill for seconds, blood pressure
145/89.
Neurological: anxious, awake and alert, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm,
productive cough
Ans>> Cardiovascular: capillary refill for seconds, blood pressure 145/89.
Neurological: anxious, restless.
Respiratory: oxygen saturation 90% on room air, respiratory rate 28 bpm.
9. NGN: The client is a 49-year-old male who reports flu like symptoms including fever and chest congestion for four days. He came to the emergency
department last night when he was having more difficulty breathing he has a
history of 1/2 pack a day cigarette smoking for 20 years. He has no significant
medical or surgical history.
The nurse should place the client in a
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position to promote
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Ans>> Semi-Fowler , lung expansion.
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10. NGN: Orders: 0330: place the client on a cardio respiratory monitor, NPO,
sputum culture, start a PIV, start oxygen 3L via nasal cannula, normal saline
150 ML per hour, acetaminophen 350mg PO every six hours for temp greater
than 101F, chest x-ray.
0500: Oxygen 8Lvia simple facemask, titrate to keep oxygen saturation greater
than 94%.
(mark whether the statements by the new grad nurse indicate understanding
or no understanding of the use of facemask in the care of this client)
-I should clean the facemask once per shift.
-The client should take a 1 to 2 minute break from the facemask each hour.
-I should put gauze under the elastic straps over the ears.
-I can adjust the oxygen level on the flow meter to keep the clients oxygen
saturation greater than 94%.
-The mask should cover only the mouth and leave the nose open for expiration.
-I should place the mask first over the nose and then cover the mouth
Ans>> -I should clean the facemask once per shift. (UNDERSTANDING)
-The client should take a 1 to 2 minute break from the facemask each hour. (NOT
UNDERSTANDING)
-I should put gauze under the elastic straps over the ears. (NOT UNDERSTANDING
????)
-I can adjust the oxygen level on the flow meter to keep the clients oxygen saturation
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greater than 94%. (UNDERSTANDING)
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-The mask should cover only the mouth and leave the nose open for expiration. (NOT
UNDERSTANDING)
-I should place the mask first over the nose and then cover the mouth. (UNDERSTANDING)
11. NGN: Nurses Notes: 0400, the client is awake and alert but restless. He
states I am feeling extremely anxious right now. The client has decreased
breath sounds in the left lower lobe. His mucus membranes are dry. He has
a productive cough with thick, yellow secretions. His capillary refill is four
seconds. Heart rate 101 BPM, oxygen saturation 90%. Blood pressure 145/89,
temperature 100.2 F, respiratory rate 28 BPM.
0500: Placedthe client in semi-Fowlers position. No improvement in oxygen
saturation on 3L nasal cannula...
(Which are the three most important goals?)
A) The client will remain free of skin breakdown.
B) The client will have quit smoking.
C) The client will be afebrile for 24 hours.
D) The client will maintain oxygen saturation of 96% without supplemental
oxygen.
E) The client will report pain less than 3/10
Ans>> B) The client will have quit smoking.
C) The client will be afebrile for 24 hours.
E) The client will report pain less than 3/10.
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12. The nurse has completed the diet teaching of a client who is being discharged following treatment of a leg wound. A high-protein diet is encouraged
to promote wound healing. Which lunch toys by the client indicates that the
teaching was effective?
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A) A peanut butter sandwich with soda and cookies.
B) Vegetable soup, crackers, and milk.
C) A tuna fish sandwich with chips and ice cream.
D) A salad with three kinds of lettuce and fruit
Ans>> C) A tuna fish sandwich with chips and ice cream.
13. A client with foul-smelling drainage from an incision on the upper left arm
is admitted with a suspected MRSA. Which nursing intervention should the
nurse include in the plan of care? SATA.
A) Institute contact precautions for staff and visitors.
B) Use standard precautions and wear a mask.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
E) Explain the purpose of a low bacteria diet
Ans>> A) Institute contact precautions for staff and visitors.
C) Send wound drainage for culture and sensitivity.
D) Monitor the clients white blood cell count.
14. An adult client who is admitted to the mental health unit for treatment of
bipolar disorder has a slightly slurred speech pattern and an unsteady gait.
Which assessment finding is most important for the nurse to report to the
healthcare provider?
A) Weight loss of 10 pounds in the past month.
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B) Six hours of sleep in the past three days.
C) Blood alcohol level of 0.09%.
D) Serum lithium level of 1.6
Ans>> D) Serum lithium level of 1.6.
15. When conducting diet teaching for a client who is on a post operative full
liquid diet, which foods should the nurse encouraged the client to eat? SATA.
A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
D) Creamy peanut butter.
E) Canned fruit cocktail
Ans>> A) Clear beef broth.
B) Vanilla frozen yogurt.
C) Vegetable juice.
16. An infant born with esophageal atresia and tracheoesophageal fistula receives a prescription for internal feedings after corrective surgery.To promote
10 /