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HESI EXIT V3 EXAM
with NGN Questions and Rationalized Answers,
100% VERIFIED NEWEST VERSION.
The exam has: 160 Multiple-choice questions
Performance Score is Above 1100
1. The nurse assumes care of a postoperative adult client with diabetes
mellitus and learns that the client has a current blood glucose level of 720
mg. When assessing the client what is the priority?
A. Assess for vital signs of fluid volume deficit.
B. Observe wound drainage characteristics.
C. Measure the level of acute pain.
D. Determine when the client last ate.
Ans: a. Assess for vital signs of fluid volume deficit.
a blood glucose level of 720 mg/dL is significantly elevated and may indicate a state
of hyperosmolar hyperglycemic state or diabetic ketoacidosis. Both conditions can
lead to fluid volume deficit. Assessing for signs of dehydration, such as altered vital
signs and dry mucous membranes, is a priority.
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2. A male client tells the nurse that he is concerned that he may have a stomach
ulcer because he is experiencing heartburn and a dull gnawing pain. Which is
the *best* response by the nurse?
A. Encourage the client to obtain a complete physical exam since these
symptoms are consistent with an ulcer.
B. Assure the client that his symptoms may only reflect reflux, since ulcer pain
is not relieved with food.
C. Instruct the client that these mild symptoms can generally be
controlled with changes in his diet.
D. Advise the client that he needs to seek immediate medical evaluation
and treatment for these symptoms.
Ans: a. encourage the client to obtain a complete physical exam since these
symptoms are consistent with an ulcer
This response is the most appropriate because it encourages the client to seek
a professional medical evaluation, which is necessary to accurately diagnose and
treat potential ulcers. While the symptoms described by the client could indeed
be indicative of an ulcer, they could also be related to other gastrointestinal
issues.
A complete physical exam by a healthcare provider is necessary to determine the
exact cause and appropriate treatment.
3. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving
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Lactated Ringer' IV. One hour after admission to the unit, the nurse notes
300 mL of blood in the suction canister, the client's heart rate is 155 beats/minute. In
addition to reporting the findings to the surgeon, which action should the nurse
implement *first?*
A. Measure and document the client's urinary output.
B. Request the client's reserved unit of packed red blood cells.
C. Prepare for the placement of central venous catheter.
D. Increase the infusion rate of Lactated Ringer's solution.
Ans: d. increase the infusion rate of Lactated Ringer's solution
The client's symptoms are indicative of acute blood loss and potential hypovolemia.
Increasing the infusion rate of IV fluids, such as Lactated Ringer's solution, is a
critical first step in managing potential hypovolemic shock. This will help to maintain
circulatory volume and perfusion until blood products can be administered or other
interventions can be performed.
4. A heparin infusion is prescribed for a client who weighs 220 pounds. After
administering a bolus dose of 80 units/kg the nurse calculates infusion rate
for the heparin solution at 18 units/kg/hour. The available solution is Heparin
Sodium 25,000 Units in 5% Dextrose Injection 250 mL. The nurse should
program the infusion pump to how many mL/hour?: 18
5. An adult male who fell 20 feet from the roof of his home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). The nurse
notes that the suction control chamber is bubbling at the -10 cm H2O mark
with fluctuation in the water seal, and over the past hour 75 mL of bright red
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blood is measured in the collection chamber. Which intervention should the
nurse implement?
A. Add sterile water to the suction control chamber
B. Give blood from the collection chamber as autotransfusion
C. Manipulate blood in tubing to drain into the chamber
D. Increase wall suction to eliminate fluctuation in water sea
Ans: c. manipulate blood in tubing to drain into the chamber
The presence of bright red blood in the collection chamber, especially after a
significant trauma like a 20-foot fall, indicates ongoing bleeding. The nurse should
ensure that all blood in the chest tube is drained into the collection chamber to
accurately monitor the client's bleeding. This can involve gently milking or stripping
the tubing to facilitate drainage, although this must be done with care to avoid
creating excessive negative pressure in the chest tube system.
6. An adult male was diagnosed with stage IV lung cancer three weeks ago.
His wife approaches the nurse and asks how she will know that her husband's
death is imminent because their two adult children want to be there when he
dies. Which is the *best* response by the nurse?
A. Gather information regarding how long it will take for the children to arrive
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B. Explain that the client will start to lose consciousness and the body systems will slow down.
C. Reassure the spouse that the healthcare provider will notify when to call the
children.
D. Offer to discuss the client's health status with each of the adult children.
Ans: b. Explain that the client will start to lose consciousness and the body systems
will slow down.
in providing end-of-life care, it's important it communicate honestly and sensitively
with family; explaining the expected changes in the client's condition as death
approaches can help prepare them for what to expect; symptoms such as loss of
consciousness, slowing of body systems, and changes in breathing patterns are
common as the end of life nears
7. The charge nurse of a critical carry unit is informed at the beginning of the
shift that lesss than the optical number of registered nurses will be working
that shift and planning assignments which client should receive the most care
hours by registered nurse (RN)?
A. 48 year olds marathon runner with a central venous catheter who is experiencing nausea and vomiting due to electrolyte disturbance following a race
B. 34 year old admitted today after an emergency appendectomy who has a
peripheral intravenous catheter and a Foley catheter
C. 63-year-old chain smoker admitted with chronic bronchitis who is receiving
oxygen via nasal cannula and has a saline-locked peripheral intravenous
catheter
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D. An 82-year-old's client with Alzheimer's disease and newly fractured femur
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who has a Foley catheter and soft wrist restraint supplied
Ans: d. An 82-year-old client with Alzheimer's disease and a newly fractured femur
who has a Foley catheter and soft wrist restraints applied
This patient presents a complex care situation. The combination of Alzheimer's
disease and a new fracture suggests a high risk for confusion, agitation, and
potential harm (e.g., attempting to walk and further injuring themselves). The use of
restraints also necessitates close and frequent monitoring to prevent complications
like skin breakdown or more severe agitation.
8. The nurse is preparing a dose of 60 mcg of teriparatide. The medication is
labeled "750 mg/2.4 mL." How many mL should the nurse administer?: 0.2
9. In caring for a client with Cushing's syndrome which serum laboratory value
is most important for the nurse to monitor?
A. Creatinine
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B. Lactate
C. Glucose
D. Hemoglobin
Ans: c. Glucose
Cushing's syndrome is characterized by an excess of cortisol in the body, which
can significantly impact glucose metabolism. This excess cortisol can lead to hyperglycemia (high blood sugar levels), making it crucial to regularly monitor the client's
glucose levels. Managing blood sugar is an important aspect of caring for a client
with Cushing's syndrome to prevent complications associated with hyperglycemia.
10. A client who received hemodialysis yesterday is experiencing a blood
pressure of 200/100 mmHg, heart rate 110 beats/minute, and respiratory rate
36 breaths/minute. The client is manifesting shortness of breath bilateral 2+
pedal edema in an oxygen saturation on a room air of 89% which action should
the nurse take first?
A. Elevate the foot of the bed
B. Restrict the client's fluids
C. Begin supplemental oxygen
D. Prepare client for hemodialysis
Ans: c. Begin supplemental oxygen
the client is experiencing signs of fluid overload and respiratory distress, which could
be related to the recent hemodialysis
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11. When caring for a client with full thickness burns to both lower extremities,
which assessment findings warrant immediate invention? (Select all that
apply)
A. Sloughing tissue around wound edges
B. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses.
D. Loss of sensation to the left lower extremity
E. Weeping serosanguineous fluid from wounds
Ans: b. Complaint of increased pain and pressure
C. Change in the quality of the peripheral pulses.
D. Loss of sensation to the left lower extremity
B: This could indicate the development of compartment syndrome, especially in
the case of circumferential burns. Compartment syndrome is a medical emergency
where pressure builds up within the muscles, which can lead to muscle and nerve
damage. Increased pain and pressure in the context of burns are concerning signs
that require urgent evaluation and intervention.
C: Change in the quality of peripheral pulses: A change in the quality of peripheral
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pulses can indicate compromised blood flow to the affected extremities. This can be
due to swelling or other circulatory issues related to the burn injury. It's crucial to
assess and address any changes in circulation to prevent further complications.
D: Loss of sensation to the left lower extremity: Loss of sensation could be an
indication of nerve damage or severe tissue damage. This is a concerning sign,
especially in the context of full thickness burns, and requires prompt assessment
and intervention
12. An older client is admitted with fluid volume deficit and dehydration.Which
assessment finding is the best indicator of hydration that the nurse should
report to the healthcare provider?
A. Urine specific gravity is 1.040
B. Systolic blood pressure decreases 10 points when standing
C. The client denies being thirsty
D. Skin tenting occurs when the clients forearm is pinched
Ans: a. urine specific gravity is 1.040
this indicates concentrated urine and is a significant indicator of dehydration; it
reflects the kidney's attempt to conserve water in response to fluid volume deficit
13. The healthcare provider prescribes methylergonovine maleate for a postpartum client with uterine atony. What finding should indicate to the nurse to
withhold the next dose of the medication?
A. Difficulty locating the uterine fundus
B. Excessive lochia
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C. Saturation of more than one pad per hour
D. Hypertension
Ans: d. Hypertension
If the client develops hypertension, it could be a side effect of methylergonovine
maleate, and the medication should be withheld and the healthcare provider notified.
Methylergonovine is contraindicated in clients with hypertension due to the risk of
exacerbating high blood pressure and potentially causing severe complications.
14. After an inservice about electronic health record (EHR) security and safeguarding client information, the nurse observes a colleague going home with
printed copies of client information and a uniform packet. Which action should
the nurse take?
A. File a detailed incident report with the specific hiring facility
B. Why did the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse
Ans: d. communi- cate the colleague's actions to the unit charge nurse