HESI RN Final EXIT Exam| 2023/ 2024| 180 Questions and Verified Answers with Rationales| 100% Correct
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HESI RN Final EXIT Exam| 2023/ 2024| 180 Questions and Verified Answers with Rationales| 100% Correct
HESI RN Final EXIT Exam| 2023/ 2024| 180
Questions and Verified Answers with
Rationales| 100% Correct
Q: The nurse performs an assessment of a newborn boy. The nurse is MOST concerned if
which of the by which observation?
1. The respiratory rate is 40 per minute with short periods of apnea.
2. The heart rate is 140 beats per minute with variation during sleeping and waking states.
3. A sudden loud noise causes abduction of the infant's arms and flexion of his elbows.
4. Stroking the outer sole of the infant's foot upward causes his toes to curl downward.
1) Assessment: outcome not a problem; 30-60 breaths/min with periods of apnea; normal
2) Assessment: outcome not a problem; 120-160/minute; varies while asleep and awake
3) Assessment: outcome not a problem; startle reflex; normal until 4 months
4) Answer: Assessment: outcome not expected and is a problem; Babinski reflex; in newborn,
should see dorsiflexion of big toe
Q: The nurse cares for the client diagnosed with type 2 diabetes. The client is scheduled for a
renal computed tomography scan with contrast media at 10 a.m. The nurse is MOST concerned
if the client makes which statement?
1. "My blood sugar was 124 mg/dL this morning."
2. "I drank a glass of water at midnight."
3. "Sometimes I get dizzy when I first get out of bed."
4. "I took my metformin (Glucophage ER) at 6 A.M. this morning."
1) Assessment: outcome not desired but not priority; further assessment needed
2) Implementation: outcome not a problem; NPO for 8 hours prior to scan
3) Assessment: outcome not desired but not priority; possible orthostatic hypotension; further
assessment needed
4) Correct - Implementation: outcome not desired and priority; metformin should be held for 48
hours prior to tomography with contrast media; risk lactic acidosis with potential renal damage
Q: The nurse cares for clients in a mental health center. The nurse observes the client, formerly
homeless and malnourished, diagnosed with chronic schizophrenia putting food from lunch into
a plastic bag. Which statement by the nurse is MOST appropriate?
1. "We don't allow people to take food from the dining room."
2. "What are you going to do with the food?"
3. "We will be serving snacks and juice at 3 P.M."
4. "Let's go watch a movie with the others."
1) Implementation: outcome not desired; judgmental; non-therapeutic communication
2) Assessment: outcome not desired; non-therapeutic; "why" questions make client defensive,
feel threatened
3) Answer: Implementation: outcome desired; reality orientation; talk with client in nonthreatening way about her needs
4) Implementation: outcome not desired; misses opportunity to reality test; distraction used for
small children and manic clients
Q: The nurse plans care for a client admitted with fever, vomiting, and diarrhea. Which
laboratory value demonstrates an improvement in the client's condition?
1. Specific gravity of urine 1.020 and hematocrit 42%.
2. Specific gravity of urine 1.039 and hematocrit 50%.
3. Specific gravity of urine 1.010 and hematocrit 52%.
4. Specific gravity of urine 1.030 and hematocrit 35%.
1) Answer: Assessment: outcome expected; normal specific gravity of urine, normal
hematocrit; specific gravity and hematocrit increase with dehydration
2) Assessment: outcome not expected; increased specific gravity of urine, increased hematocrit;
suggests ongoing fluid volume deficit
3) Assessment: outcome not expected; decreased specific gravity of urine, increased hematocrit;
does not indicate improvement
4) Assessment: outcome not expected; increased specific gravity of urine, decreased hematocrit;
does not indicate improvement
Q: The nurse cares for a client who is to receive thrombolytic therapy with tissue plasminogen
activator (rtPA). The nurse is MOST concerned if the client makes which of the following
statements?
1. "I take a multivitamin tablet daily for cold and flu prevention."
2. "I had major abdominal surgery a year ago."
3. "I get some stomach pain when I eat spicy foods."
4. "I hit my head and lost consciousness during a car accident 2 months ago."
1) Implementation: outcome not a problem; no interaction
2) Implementation: outcome not a problem; surgery within 3 weeks is potential contraindication
3) Implementation: outcome not a problem; active peptic ulcer disease is potential
contraindication; needs further investigation
4) Answer: Implementation: outcome a problem; significant traumatic head injury within 3
months is an absolute contraindication for thrombolytic therapy
Q: A 60-year-old client comes to the outclient clinic to receive the influenza vaccine. Which of
the following questions, if asked by the nurse, is BEST?
1. "Have you had the flu in the past month?"
2. "Do you have any food allergies?"
3. "Has anyone in your family been sick?"
4. "Are you allergic to any medication?"
1) Assessment: outcome not priority; immunization deferred in presence of acute respiratory
disease or other acute infection
2) Answer: Assessment: outcome priority; allergy to eggs is a contraindication to receiving flu
vaccine
3) Assessment: outcome not priority; immunization deferred only if client has active infection
4) Assessment: outcome not priority; medication allergy not pertinent
Q: The home care nurse is visiting an alert, oriented woman living with her daughter. The client
is malnourished and has multiple bruises on her body, and the situation is reported to the
appropriate authority. After counseling the client and daughter, the nurse notes the situation has
not improved. The client decides to remain with her daughter. Which action, if taken by the
nurse, is MOST appropriate?
1. Respect the client's decision to stay in her daughter's home.
2. Insist the client move in with her other child.
3. Begin guardianship procedures.
4. Place live-in help in the home.
1) Answer: Implementation: outcome desired; intervention not possible without consent of the
senior if person is legally competent; further assessment needed to determine cause of bruises
2) Implementation: outcome not desired; legally competent senior can choose where to live and
with whom
3) Implementation: outcome not desired; appropriate if senior is legally incompetent and in
immediate danger
4) Implementation: outcome not desired; must have consent of client
Q: A news reporter and camera person arrive on the nursing unit to videotape an interview of a
client. When the nurse refuses their request, the reporter references his First Amendment rights.
Which statement, if made by the nurse, is MOST appropriate?
1. "Why do you want to talk with the client?"
2. "I'll ask the client if he is ready to speak with you."
3. "I will need to call the nurse manager about your request."
4. "Does the client know that you are coming?"
1) Assessment: outcome not priority; don't ask "why" questions on the NCLEX-RN®; "why"
questions are considered to be confrontational
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