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2026 HESI RN EXIT EXAM V1 (3 SETS)|300Qs&As |NEW UPDATE|ALREADY GRADED A+, Exams of Nursing

California State University (CSU) - Fresno Nursing

2026 HESI RN EXIT EXAM V1 (3 SETS)|300Qs&As |NEW UPDATE|ALREADY GRADED A+

Typology: Exams

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Available from 01/14/2026

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2026 HESI RN EXIT EXAM V1 (3

SETS)|300Qs&As |NEW UPDATE|ALREADY

GRADED A+

1. Which information is most concerning to the nurse when caring for an older client with bilateral

cataracts?

a. States having difficulty with color perception

b. Presents with opacity of the lens upon assessment

c. Complains of seeing a cobweb-type structure in the visual field

d. Reports the need to use a magnifying glass to see small print

Rationale:

Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment,

which constitutes a medical emergency. Clients with cataracts are at increased risk for

retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss

are expected signs and symptoms of cataracts but do not need immediate attention.

2. When caring for a client hospitalized with Guillain-Barré syndrome, which information is most

important for the nurse to report to the primary health care provider?

a. Decrease in cognitive status of the client

Rationale:

A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible need to assist the

client with mechanical ventilation. A primary health care provider will need to be contacted immediately.

Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but

are not as critical as the client's hypoxic status.

3. A client is admitted with a diagnosis of leukemia. This condition is manifested by which of

the following?

a. Hyperplasia of the gums, elevated white blood count, weakness

Rationale:

Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia.

Options A, B, and D state incorrect information for symptoms of leukemia.

4. The nurse enters the examination room of a client who has been told by her health care provider

that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the

client?

Discover Exams of Nursing California State University (CSU) - Fresno

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Download 2026 HESI RN EXIT EXAM V1 (3 SETS)|300Qs&As |NEW UPDATE|ALREADY GRADED A+ and more Exams Nursing in PDF only on Docsity!

2026 HESI RN EXIT EXAM V1 (

SETS)|300Qs&As |NEW UPDATE|ALREADY

GRADED A+

Which information is most concerning to the nurse when caring for an older client with bilateral cataracts? a. States having difficulty with color perception b. Presents with opacity of the lens upon assessment c. Complains of seeing a cobweb-type structure in the visual field d. Reports the need to use a magnifying glass to see small print Rationale: Visualization of a cobweb- or hairnet-type structure is a sign of a retinal detachment, which constitutes a medical emergency. Clients with cataracts are at increased risk for retinal detachment. Distorted color perception, opacity of the lens, and gradual vision loss are expectedsigns and symptoms of cataracts but do not need immediate attention.
When caring for a client hospitalized with Guillain-Barré syndrome, which informationis most important for the nurse to report to the primary health care provider? a. Decrease in cognitive status of the client Rationale: A decline in cognitive status in a client is indicative of symptoms of hypoxia and a possible needto assist the client with mechanical ventilation. A primary health care provider will need to be contacted immediately. Options A, C, and D are findings associated with Guillain-Barré syndrome that should also be reported but are not as critical as the client's hypoxic status.
A client is admitted with a diagnosis of leukemia. This condition is manifested bywhich of the following? a. Hyperplasia of the gums, elevated white blood count, weakness Rationale: Hyperplastic gums, weakness, and elevated white blood count are classic signs of leukemia. Options A, B, and D state incorrect information for symptoms of leukemia.
The nurse enters the examination room of a client who has been told by her health careprovider that she has advanced ovarian cancer. Which response by the nurse is likely to be most supportive for the client?

a. " Tell me about what you are feeling right now." Rationale: The most therapeutic action for the nurse is to be an active listener and to encourage the client toexplore her feelings. Giving false reassurance or personal suggestions are not therapeutic communication for the client.

A nurse working in the emergency department admits a client with full thickness burnsto 50% of the body. Assessment findings indicate high-pitched wheezing, heart rate of 120 beats/min, and disorientation. Which action should the nurse take first? a. Prepare to assist with maintaining the airway. Rationale: High-pitched wheezing indicates laryngeal stridor, a sign of laryngeal edema associated with lung injury. Airway management is the first priority of care. Options A, C, and D are all appropriate interventions in managing the client with a burn but are not as critical as establishingan airway.
The nurse walks into the room and observes the client experiencing a tonic- clonicseizure. Which intervention should the nurse implement first? a. Turn the client on the side to aid ventilation. Rationale: Maintaining the airway during a seizure is the priority for safety. Options A, B, and C are contraindicated during a seizure and may cause further injury to the client.
Which intervention should be included in the plan of care for a client admitted to thehospital with ulcerative colitis? a. Provide a low-residue diet. Rationale: A low-residue diet will help decrease symptoms of diarrhea, which are clinical manifestations ofulcerative colitis.
A nurse implements an education program to reduce hospital readmissions for clientswith heart failure. Which statement by the client indicates that teaching has been effective? a. "I will not take my digoxin if my heart rate is higher than 100 beats/min." b. " I should weigh myself once a week and report any increases." c. "It is important to increase my fluid intake whenever possible." d. "I should report an increase of swelling in my feet or ankles." Rationale: An increase in edema indicates worsening right-sided heart failure and should be reported to the primary health care provider. Digitalis should be held when the heart rate is lower than 60 beats/min. The client with heart failure should weigh himself or herself daily and report a gain of 2 to 3 lb. An increase in fluid can worsen heart failure.

The apical heart rate of 130 beats/min is a critical finding that could lead to heart failureor other cardiac disorders.

The nurse administers atropine sulfate ophthalmic drops preoperatively to the right eye of a client scheduled for cataract surgery. Which response by the client indicates that the drug was effective? a. The right pupil dilates after drop instillation. Rationale: Atropine is a mydriatic drug which causes pupil dilation and paralysis in preparation for surgeryor examination.
A client with human immunodeficiency virus (HIV) develops a painful blistering skin rash onthe right lateral abdominal area. Which drug should the nurse expect to administer to treat this condition? a. Levofloxacin b. Acyclovir sodium c. Fluconazole d. Esomeprazole Rationale: The clinical manifestations listed are consistent with herpes zoster (shingles). Acyclovir sodiumis an antiviral used to treat herpes zoster or shingles. Levofloxacin is an antibiotic and may be used to treat pneumonia or other infections in the HIV client. Fluconazole is an antifungal and isused to treat candidiasis in the HIV client. Esomeprazole is a protein pump inhibitor used for gastroesophageal reflux disease.
When assessing a 38 - year-old client with tuberculosis who is taking rifampin, which findingwould be most important to report to the primary health care provider immediately? a. Orange-colored urine b. Potassium level, 4.9 mEq/L c. Elevated liver enzyme levels d. Blood urea nitrogen (BUN) level, 12 mg/dL. Rationale: Rifampin can cause hepatotoxicity, so elevated liver enzyme levels need to be closely monitoredand reported to the health care provider. Orange discoloration of the urine is an expected side effect of this medication. The potassium level is normal. A BUN level of 12 mg/dL is within defined parameters.
A client with non-Hodgkin lymphoma has been prescribed cyclophosphamide IV fortherapy. Which assessment finding would need to be reported immediately to the oncologist? a. Chills, fever, and sore throat Rationale: Cyclophosphamide is an immunosuppressive drug used to treat lymphoma and puts the client atrisk for infection. Signs and symptoms of an infection should be reported to the oncologist immediately.

A nurse is assessing a client with heart failure who has been prescribed digoxin fortherapy. Which finding indicates an issue with the medication management? a. Serum potassium level, 2.9 mEq/L Rationale: A serum potassium level of 2.9 mEq/L is low, and side effects of digoxin toxicity are exacerbatedwhen the potassium level is low.
Which statement by the U.S. Food and Drug Administration (FDA) is an example of ablack box or black label warning for the drug clopidogrel? a. This drug could cause heart attack or stroke when taken by clients with certain geneticconditions. Rationale: A black box warning is a notice required by the FDA on a prescription drug that warns of potentially dangerous side effects. 20. The nurse is caring for a client with an ischemic stroke who has a prescription for tissue plasminogen activator (t-PA) IV. Which actions should the nurse expect to implement? (Select all that apply.) a. Complete the National Institute of Health Stroke Scale (NIHSS). b. Assess the client for signs of bleeding during and after the infusion. c. Start t-PA within 6 hours after the onset of stroke symptoms. Rationale: Neurologic assessment, including the NIHSS, is indicated for the client receiving t- PA. This includes close monitoring for bleeding during and after the infusion; if bleeding or other signs ofneurologic impairment occur, the infusion should be stopped
Which action by the nurse is consistent with culturally competent care? a. Treating each client the same regardless of race or religion b. Ensuring that all Native American clients have access to a shaman c. Understanding one's own world view in addition to the client’s d. Including the family in the plan of care for older clients Rationale: The nurse should understand his or her own values and views to prevent those values from beingimparted to others, in addition to understanding the client's cultural views. Treating every client the same or assuming that all clients share the same values does not exhibit cultural competence or sensitivity.
The charge nurse reviews the charting of a graduate nurse. Which indicates a need forfurther education on documentation? a. Charts some actions in advance of performing them. Rationale:

The use of personal protective equipment (PPE) for airborne precautions includes a properly pre-fitted N respirator or mask. A surgical mask is used for preventing transmission of droplet precautions.

The nurse reviews the comprehensive metabolic panel for a client with an electrolyte imbalance. Which data requires the most immediate intervention by the nurse? a. Sodium level, 125 mEq/L Rationale: The normal serum sodium level is 135 to 145 mEq/L. This value indicates hyponatremia. Symptoms of hyponatremia include nausea and vomiting, headache, confusion, and seizures, which can be severe and need immediate attention.
A client is admitted to the hospital with the diagnosis of hypokalemia. Which clinical manifestation is most significant? a. Heart palpitations Rationale: Hypokalemia can cause heart palpitations, which are indicative of a dysrhythmia that couldprogress to a medical emergency.
The nurse prepares to administer 3 units of regular insulin and 20 units of NPH insulin subcutaneously to a client with an elevated blood glucose level. Which procedure iscorrect? a. Using one syringe, add the regular insulin into the syringe and then add the NPH insulin. Rationale: The regular or "clear" insulin should be withdrawn into the syringe first, followed by the NPH. Air should first be injected into the NPH vial and then air should be inserted into the regular vial. NPH and regular insulin are compatible, and combining will reduce the number of injections. The insulin is ordered subcutaneously and NPH cannot be given IV.
The nurse is caring for a client in the medical unit. Which task can be delegated to unlicensed assistive personnel (UAP)? a. Obtain a fingerstick blood glucose level. Rationale: Obtaining a fingerstick blood glucose level is a simple treatment and is an appropriate skill forUAP to perform. Options A, C, and D are skills that cannot be delegated to UAP.
Which disaster management intervention by the nurse is an example of primary prevention? a. Education of rescue workers in first aid Rationale: Primary prevention is aimed at preventing disease or injury. Training rescue workers prior to adisaster is an example of minimizing or preventing injury.

33. The nurse teaches a class on bioterrorism. Which methods of transmission arepossible with the biologic agent Bacillus anthracis (Anthrax)? (Select all that apply.) a. Inhalation of powder form b. Handling of infected animals c. Eating undercooked meat from infected animals d. Direct cutaneous contact with the powder Rationale: Anthrax can be transmitted by the inhalation, cutaneous, and digestive routes (A, B, D, and E)

The nurse assesses a pressure ulcer on a client's heel and notes full-thickness tissue loss, withsome visible subcutaneous fat. How should the nurse stage this pressure ulcer? a. Stage III Rationale: The statement above describes a stage III ulcer, which is defined as full-thickness tissue loss in which subcutaneous fat may be exposed but without exposure of bone, tendon, or muscle. A stage I ulcer includes intact skin with non-blanchable redness of a localized area. A stage II ulceris described by partial-thickness loss of dermis, including a shallow open ulcer with a pinkish redwound bed. Full- thickness tissue loss with exposed bone, tendon, or muscle and slough or eschar is indicative of a stage IV ulcer.
The nurse prepares to administer ophthalmic drops to a client prior to cataract surgery. Listthe steps in the order that they should be implemented from first step to final step.
Drop prescribed number of drops into conjunctival sac.
Wash hands and apply clean gloves.
Place the dominant hand on the client’s forehead.
Ask the client to close the eye gently. B. 2, 3, 1, 4 Rationale: Washing hands and applying gloves prior to procedure initiation prevents the spread of infection (2). Placing the dominant hand on the client’s forehead (3) stabilizes the hand sothe nurse can hold the dropper 1 to 2 cm above the conjunctival sac and drop the prescribed number of drops (1); asking the client to close the eye gently helps distribute the medication (4).
The nurse is caring for a client who is experiencing severe pain. The expected outcome the nurse writes for the client reads, "The client will state my pain is <2 within 45 minutes after painmedication has been administered." Formulating the expected outcome is an example of which step in the nursing process? a. Planning Rationale:

a. "The Health Insurance Portability and Accountability Act (HIPAA) prevents me fromrepeating what you say." b. "You can be assured that I will keep all of our conversations confidential because it isimportant that you can trust me." c. "For your safety and well-being, it may be necessary to share some of our conversationswith the health care team." d. "I am legally required to document all of our conversations in the electronic medicalrecord." Rationale: Some information, such as a suicide plan, must be shared with other team members for the client's safety and optimal therapy. HIPAA does not prevent a member of the health care teamfrom repeating all conversations, particularly if safety is an issue. Ensuring a client that a conversation will remain confidential puts the nurse at risk, particularly if safety is an issue. Although pertinent information should be documented, the nurse is not legally required to document all conversations with a client.

Which intervention is most important when caring for a client immediately after electroconvulsive therapy (ECT)? a. Reorient the client to surroundings. b. Assess blood pressure every 15 minutes. c. Determine if muscle soreness is present. d. Maintain a patent airway. Rationale: The client is typically unconscious immediately following ECT, and nausea is a common sideeffect. The nurse should take measures to prevent aspiration and maintain a patent airway. Clients may be confused after ECT, but reorientation is not as high a priority as the airway. Although vital signs should be assessed, the airway is a higher priority. Muscle soreness is anexpected finding after ECT.
A client in the psychiatric setting with an anxiety disorder reports chest pain. Whichaction should the nurse take first? a. Administer an antianxiety medication PRN. b. Assess the client's vital signs. c. Notify the primary health care provider. d. Determine coping mechanisms used in the past. Rationale: Although increased heart rate, palpitations, and chest pain may be caused by anxiety, it is important that the nurse assess the client and rule out physiologic causes. Nonpharmacologic measures should be taken first. Options C and D may be considered but are not as high priority as the initial physiologic assessment.
The nurse is assessing suicide risk for a client recently admitted to the acute psychiatric unit. Which finding is the most significant risk factor? a. High level of anxiety present

b. History of previous suicide attempt c. Family history of depression d. Self-care deficit is noted Rationale: A previous history of a suicide attempt is the most significant risk factor for future suicide attempts because the client has previously implemented a plan. Options A, C, and D may also berisk factors but are not as significant as a history of previous attempts.

A client who is prescribed chlorpromazine HCl for schizophrenia develops rigidity, ashuffling gait, and tremors. Which action by the nurse is most important? a. Administer a dose of benztropine mesylate PRN. b. Determine if the client has increased photosensitivity. c. Provide comfort measures for sore muscles. d. Assess the client for visual and auditory hallucinations. Rationale: Rigidity, shuffling gait, pill-rolling hand movements, tremors, dyskinesia, and masklike face are extrapyramidal side effects associated with chlorpromazine. It is most important for the nurse to administer an anticholinergic such as benztropine mesylate to reverse these effects. Options B, C,and D may be appropriate interventions but are not as urgent as option A.
A nurse is interviewing a mother during a well-child visit. Which finding would alertthe nurse to continue further assessment of the infant? a. Two-month-old who is unable to roll from back to abdomen b. Ten-month-old who cannot sit without support c. Nine-month-old who cries when his mother leaves the room d. Eight-month-old who has not yet begun to speak words Rationale: As a developmental milestone, infants should sit unsupported by 8 months. The milestone of rolling over is achieved at 5 to 6 months for most infants. Stranger anxiety is common from 7 to 9 months. Speaking a few words is expected at about 12 months.
Which vaccination should the nurse administer to a newborn? a. Hepatitis B b. Human papilloma virus (HPV) c. Varicella d. Meningococcal vaccine Rationale: The hepatitis B vaccination should be given to all newborns before hospital discharge. HPV isnot recommended until adolescence. Varicella immunization begins at 12 months. Meningococcal vaccine is administered beginning at 2 years.

Rationale: 66 lb/(2.2 kg/lb) = 30 kg 30 kg × (15 mg/kg) = 450 mg (5 mL/150 mg) × 450 mg = 15 mL or (450 mg/150 mg) × 5 mL = 15 mL

The nurse expects a clinical finding of cyanosis in an infant with which conditions? (Select all that apply.) a. Ventricular septal defect (VSD) b. Patent ductus arteriosus (PDA) c. Coarctation of the aorta d. Tetralogy of Fallot e. Transposition of the great vessels Rationale: Both tetralogy of Fallot and transposition of the great vessels are classified as cyanotic heart disease, in which unoxygenated blood is pumped into the systemic circulation, causing cyanosis (D and E). (A, B, and C) are all abnormal cardiac conditions, but are classified as acyanotic and involve left-to-right shunts, increased pulmonary blood flow, or obstructive defects.
Which nursing intervention should be implemented postoperatively in an infant withspina bifida after repair of a meningocele? a. Limit fluids to prevent infection to the surgical site. b. Place the infant in the prone position. c. Provide a low-residue diet to limit bowel movements. d. Cover sac with a moist sterile dressing. Rationale: The infant should be placed in the prone position to alleviate pressure on the surgical site, whichis in the sacrum. Fluids should be increased postoperatively to prevent dehydration. A high-fiberdiet should be implemented to prevent constipation. After the repair, the sac is no longer exposed, so option D does not apply.
When caring for a hospitalized child with type 1 diabetes mellitus, which interventioncan the nurse delegate to the unlicensed assistive personnel (UAP)? a. Teach the signs and symptoms of hypoglycemia. b. Assess for polydipsia, polyphagia, and polyuria. c. Check the blood glucose level every 4 hours.

d. Evaluate the need for a snack between meals. Rationale: Checking the blood glucose level is a low-risk task that can be safely delegated to the UAP in most circumstances. Teaching, assessment, and evaluation are all within the scope of practice of the RN and should not be delegated to the UAP.

The outpatient clinic nurse is reviewing phone messages from last night. Which clientshould the nurse call back first? a. An 18 - year-old woman who had a positive pregnancy test and wants advice on how totell her parents b. A woman with type 1 diabetes who has just discovered she is pregnant and is worriedabout her fingerstick glucose c. A women at 24 weeks of gestation crying about painful genital lesions on the vulva andurinary frequency d. A women at 30 weeks of gestation who has been diagnosed with mild preeclampsia and is unable to relieve her heartburn Rationale: The women with epigastric pain should be called first. One of the cardinal signs of eclampsia, a life- threatening complication of pregnancy, is epigastric pain. Options A, B, and C are less serious and should be called after option D.
Which monitored pattern of fetal heart rate alerts the nurse to seek immediate intervention by the health care provider? a. Accelerations in response to fetal movement b. Early decelerations in the second stage of labor c. Fetal heart rate of 130 beats/min between contractions d. Late decelerations with absent variability and tachycardia Rationale: Late decelerations indicate uteroplacental insufficiency and can be indicative of complications. When occurring with absent variability and tachycardia, the situation is ominous. 130 beats/minis an expected heart rate. Options A and B are not as critical.
When caring for a client in labor, which finding is most important to report to theprimary health care provider? a. Maternal heart rate, 90 beats/min b. Fetal heart rate, 100 beats/min c. Maternal blood pressure, 140/86 mm Hg d. Maternal temperature, 100.0°F Rationale: A fetal heart rate (FHR) of 100 beats/min may indicate fetal distress because the average FHR atterm is 140 beats/min, and the normal range is 110 to 160 beats/min. Options A, C, and D are normal findings for a woman in labor.

e. Nasal flaring noted with respirations Rationale: These are normal findings (A and B). The others indicate abnormalities or complications andshould be reported to the primary health care provider (C, D, and E).

The nurse is caring for a client with heart failure who develops respiratory distressand coughs up pink frothy sputum. Which action should the nurse take first? a. Draw arterial blood gases. b. Notify the primary health care provider. c. Position in a high Fowler position with the legs down. d. Obtain a chest x-ray. Rationale: Positioning the client in a high Fowler position with dangling feet will decrease further venous return to the left ventricle. Options A, B, and D should be performed after the change in position.
When caring for a postsurgical client who has undergone multiple blood transfusions,which serum laboratory finding is of most concern to the nurse? a. Sodium level, 137 mEq/L b. Potassium level, 5.5 mEq/L c. Blood urea nitrogen (BUN) level, 18 mg/dL d. Calcium level, 10 mEq/L Rationale: Multiple blood transfusions are a risk factor for hyperkalemia. A serum potassium level higherthan 5. mEq/L indicates hyperkalemia. Options A, C, and D are normal findings.
The nurse is caring for a client with respiratory distress whose arterial blood gas (ABG) results are as follows: pH, 7.33; PCO2, 50 mm Hg; PO2, 70 mm Hg; HCO3, 26 mEq/L.How should the nurse interpret these results? a. Metabolic acidosis b. Respiratory alkalosis c. Metabolic alkalosis d. Respiratory acidosis Rationale: A pH < 7.25 and PCO2 > 45 mm Hg with a normal HCO3 indicates respiratory acidosis. OptionsA, B, and C are incorrect analyses of the ABGs.
The nurse is caring for a client who develops ventricular fibrillation. Which actionshould the nurse take first? a. Administer epinephrine. b. Defibrillate immediately. c. Give a bolus with isotonic fluid. d. Notify the health care provider.

Rationale: Defibrillation is the first and most effective emergency treatment for ventricular fibrillation.Options A, C, and D may follow the first action.

When caring for an 80 - year-old client with pneumonia, which finding is of mostconcern to the nurse? a. Decrease in level of consciousness b. BUN level, 20 mg/dL; creatinine level, 1.0 mg/dL c. Reports of a dry mouth and lips d. Fine crackles auscultated in lung bases Rationale: A decrease in level of consciousness is a sign of decreased oxygenation and requires immediateintervention. Options B, C, and D are expected findings.
The nurse is caring for a client with a cerebrovascular accident (CVA) who isreceiving enteral tube feedings. Which task performed by the UAP requires immediate intervention by the nurse? A. Suctions oral secretions from mouth B. Positions head of bed flat when changing sheets C. Takes temperature using the axillary method D. Keeps head of bed elevated at 30 degrees Rationale: Positioning the head of the bed flat when enteral feedings are in progress puts the client at riskfor aspiration. Options A, C, and D are all acceptable tasks performed by the UAP.
The nurse is caring for a client with chronic renal failure (CRF) who is receiving dialysis therapy. Which nursing intervention has the greatest priority when planning this client'scare? a. Palpate for pitting edema. b. Provide meticulous skin care. c. Administer phosphate binders. d. Monitor serum potassium levels. Rationale: Clients with CRF are at risk for electrolyte imbalances, and imbalances in potassium can be lifethreatening. One sign of fluid retention is pitting edema, but it is an expected symptom of renal failure and is not as high a priority as option D. Options B and C are common nursing interventions for CRF but not as high a priority as option D.
Which finding should be reported to the primary health care provider when caring fora client who has a continuous bladder irrigation after a transurethral resection of the prostate gland (TURP)? a. The client reports a continuous feeling of needing to void. b. Urinary drainage is pink 24 hours after surgery. c. The hemoglobin level is 8.4 g/dL 3 days postoperatively. d. Sterile saline is being used for bladder irrigation.

The nurse prepares to administer digoxin, 0.125 mg IV, to an adult client with atrial fibrillation. Which client datum requires the nurse to withhold the medication? a. The apical heart rate is 64 beats/min. b. The serum digoxin level is 1.5 ng/mL. c. The client reports seeing yellow-green halos. d. The potassium level is 4.0 mEq/L. Rationale: Reports of yellow-green halos and blurred vision are signs of digoxin toxicity. Options A, B, andC are normal findings.
The nurse in the emergency department is caring for a client with type 1 diabetesmellitus in diabetic ketoacidosis (DKA). Which action should the nurse take first? a. Administer regular insulin IV. b. Start an IV infusion of normal saline. c. Check serum electrolyte levels. d. Give a potassium supplement. Rationale: The client in DKA experiences severe dehydration and must be rehydrated before insulin is administered. Options A, C, and D will follow rehydration.
The nurse administers regular insulin (human), 8 units subcutaneously, to a client at 8:00 am, 30 minutes before breakfast. At what time is the client most at risk for a hypoglycemicreaction? a. A. 9:30 am b. B. 10:30 am c. C. 12:00 pm d. 3:00 pm Rationale: Regular insulin is short-acting and peaks between 2 and 3 hours after administration. The clientis most at risk for a hypoglycemic reaction during the peak times. Options A, C, and D are not high-risk times for the client to experience hypoglycemia because they do not fall within the peak time.
The nurse assesses a client who is taking indomethacin (Indocin) for arthritic pain.Which of the following is most important to report to the primary health care provider? a. Takes medication with milk. b. Blood pressure, 104/64 mm Hg. c. Elevated liver enzyme levels. d. Hemoglobin level, 13 g/dL. Rationale:

Indomethacin is an anti-inflammatory drug and can cause liver damage. Elevated liver enzyme levels indicate a complication with the drug. This medication should be taken with food or milkto reduce gastrointestinal (GI) side effects. Options B and D are normal findings.

The nurse is caring for a client with deep vein thrombosis who is on a continuous IVheparin infusion. The activated partial prothrombin time (aPTT) is 120 seconds. Which action should the nurse take? a. Increase the rate of the heparin infusion using a nomogram. b. Decrease the heparin infusion rate and give vitamin K IM. c. Continue the heparin infusion at the current prescribed rate. d. Stop the heparin drip and prepare to administer protamine sulfate. Rationale: An aPTT more than 100 seconds is a critically high value; therefore, the heparin should be stopped. The antidote for heparin is protamine sulfate. Increasing the rate would increase the riskfor hemorrhage. The infusion should be stopped, and vitamin K is the antidote for warfarin (Coumadin). Keeping the infusion at the current rate would increase the risk for hemorrhage.
The nurse is caring for a hospitalized client with myasthenia gravis. Which findingrequires the most immediate action by the nurse? a. O2 saturation, 89% b. Reports diplopia c. Ptosis to left eye d. Difficulty speaking Rationale: Respiratory failure is a life-threatening complication that can occur with myasthenia gravis. Options B, C, and D are signs of the disease but are not as life threatening as decreased oxygensaturation. 78. The nurse is planning the care for a client who is admitted with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which interventions should the nurseinclude in this client's plan of care? (Select all that apply.) a. Salt-free diet b. Quiet environment c. Deep tendon reflex assessments d. Neurologic checks e. Daily weights Rationale: Correct responses are (B, C, D, and E). SAIDH results in water retention and dilutional hyponatremia, which causes neurologic changes when serum sodium levels are less than 115 mEq/L. The nurse should maintain a quiet environment (B) to prevent overstimulation and assessdeep tendon reflexes (C) and perform neurologic checks (D) to monitor for neurologic deteriora-tion. Daily weights (E) should be monitored to assess for fluid overload. (A) would contribute to dilutional hyponatremia.

2026 HESI RN EXIT EXAM V1 (3 SETS)|300Qs&As |NEW UPDATE|ALREADY GRADED A+, Exams of Nursing

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Download 2026 HESI RN EXIT EXAM V1 (3 SETS)|300Qs&As |NEW UPDATE|ALREADY GRADED A+ and more Exams Nursing in PDF only on Docsity!

2026 HESI RN EXIT EXAM V1 (

SETS)|300Qs&As |NEW UPDATE|ALREADY

GRADED A+