Exit HESI Nightingale Question Bank

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Sample questions from Exit HESI Nightingale Question Bank

This material has 150 questions with answers and rationales. Here are the first 5.

1. 1.A client's potassium is 6.2 mEq/L (reference range 3.5-5.0 mEq/L), and the cardiac monitor shows peaked T waves. Which action should the nurse take first?

   • A.Encourage the client to increase oral fluids.
   • B.Offer a potassium-restricted meal.
   • C.Administer IV calcium gluconate as prescribed.
   • D.Obtain a 12-lead ECG after the next scheduled vital signs.

   Rationale: IV calcium gluconate stabilizes the cardiac membrane and is the immediate priority when hyperkalemia is accompanied by ECG changes. A potassium-restricted meal may help prevent further elevation but does not treat the current cardiac risk. Delaying the ECG and encouraging fluids do not address the potentially life-threatening dysrhythmia risk.

2. 2.In the emergency department, a 15-year-old with asthma is receiving oxygen and nebulized bronchodilators. Which finding requires immediate action?

   • A.The client's heart rate increases from 96/min to 112/min after albuterol.
   • B.The client speaks in one-word responses and has markedly diminished breath sounds.
   • C.The client has a respiratory rate of 26/min and audible expiratory wheezing.
   • D.The client reports feeling shaky after the second nebulizer treatment.

   Rationale: One-word speech with markedly diminished breath sounds suggests severe airflow obstruction and a possible silent chest, requiring immediate escalation of care. Wheezing with a moderately elevated respiratory rate is concerning but less ominous than minimal air movement. Tachycardia and shakiness are common effects of albuterol and should be monitored, but they are not the highest priority here.

3. 3.Refer to the client's chart. Which actions should the nurse take now for this 3-year-old? Select all that apply.

   • A.Notify the provider promptly about the worsening perfusion and urine output.
   • B.Administer the prescribed isotonic fluid bolus and reassess the response.
   • C.Wait for the next scheduled vital signs before intervening.
   • D.Give an antipyretic as the only intervention for the elevated temperature.
   • E.Maintain continuous monitoring and reassess capillary refill and mental status.

   Rationale: The chart shows worsening tachycardia, hypotension, delayed capillary refill, and decreasing urine output, so prompt provider notification and the prescribed fluid bolus are indicated. Continuous monitoring and reassessment are needed to evaluate perfusion and response to treatment. Waiting until the next scheduled vital signs delays care, and an antipyretic alone does not treat the signs of shock.

4. 4.Refer to the client's chart. Which action is the priority for this 77-year-old client?

   • A.Assist the client to the bathroom to obtain a stool specimen.
   • B.Give the scheduled oral iron with a small amount of water.
   • C.Recheck the blood pressure in 1 hour after the next meal.
   • D.Initiate the prescribed rapid response for suspected ongoing hemorrhage.

   Answer and rationale are in the full material.

5. 5.A client who takes warfarin asks how to reduce the risk of bleeding at home. Which statement indicates correct understanding?

   • A.I will use an electric razor and a soft-bristled toothbrush.
   • B.I will stop eating leafy green vegetables completely.
   • C.I will take ibuprofen for minor joint pain.
   • D.I will double my next dose if I forget a dose.

   Answer and rationale are in the full material.