HESI RN EXIT V2 EXAM WITH RATIONALES

HESI RN EXIT V2 EXAM WITH RATIONALES
1. A client is prescribed lisinopril for hypertension. Which of the following side effects should the nurse
instruct the client to report immediately?
A. Dry cough
B. Nausea
C. Dizziness
D. Angioedema
Answer: D
Rationale: Angioedema is a serious and potentially life-threatening side effect of ACE inhibitors like
lisinopril. The client should report it immediately.
2. A nurse is caring for a client with a chest tube following a pneumothorax. Which of the following
observations requires immediate action?
A. Fluctuation of water in the water seal chamber
B. 75 mL of drainage in the first hour
C. Continuous bubbling in the water seal chamber
D. Tidaling in the water seal chamber
Answer: C
Rationale: Continuous bubbling in the water seal chamber indicates an air leak and should be addressed
immediately.
3. A client is admitted with severe sepsis. Which of the following is the nurse’s priority intervention?
A. Administer IV fluids
B. Administer antibiotics
C. Insert a urinary catheter
D. Monitor urine output
Answer: B
Rationale: Administering antibiotics is the priority intervention for sepsis to control the infection and
prevent worsening.
4. A client with heart failure is prescribed digoxin and furosemide. Which electrolyte should the nurse
monitor most closely?
A. Sodium
B. Potassium
C. Magnesium
D. Calcium
Answer: B
Rationale: Furosemide is a diuretic that causes potassium loss, and low potassium can increase the risk
of digoxin toxicity.
5. A client with asthma is prescribed montelukast. Which of the following instructions should the
nurse include?
A. Take this medication only during an asthma attack
B. Take the medication every night
C. Stop taking if side effects occur
D. Use it as a rescue medication
Answer: B
Rationale: Montelukast is a maintenance medication for asthma and should be taken every night to
prevent attacks, not as a rescue medication.
6. A client with diabetes is prescribed insulin glargine (Lantus) at bedtime. The nurse should explain
that this insulin:
A. Peaks in 2-4 hours
B. Should be mixed with short-acting insulin
C. Has no pronounced peak
D. Can cause hypoglycemia within 1 hour of administration
Answer: C
Rationale: Insulin glargine is a long-acting insulin with no pronounced peak, reducing the risk of
nocturnal hypoglycemia.
7. A nurse is preparing to administer a blood transfusion. Which of the following actions should the
nurse take first?
A. Obtain baseline vital signs
B. Check the client’s blood type with another nurse
C. Prime the IV tubing with normal saline
D. Educate the client about signs of transfusion reaction
Answer: B
Rationale: The most important action is to verify the client’s blood type and the blood product with
another nurse to prevent transfusion reactions.
8. A client with a recent diagnosis of Addison's disease asks about treatment. Which of the following
medications should the nurse anticipate will be prescribed?

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