HESI E2 HESI Exit Exam - Set 4 - Part 1

Correct Answer: All values fall within normal infant ranges

Infant heart rate spans 90 to 160, respiratory rate 25 to 50, and normal temperature stays between 97.7 and 99.5 F. Every parameter sits inside the expected range, so reassurance is the correct response. Option b is incorrect because 130 sits in the middle of the expected infant range of 90 to 160. Labeling this rate as bradycardic would push the nurse to chase a problem that does not exist. Option c is incorrect because infants normally breathe 25 to 50 times per minute, and 35 is unremarkable. Respiratory distress would show retractions, nasal flaring, grunting, or sustained rates above 60, none of which appear here. Option d is incorrect because the temperature sits within the normal range of 97.7 to 99.5 F for infants. Fever begins above 100.4 F rectal, and there is no evidence of elevated thermal status here.

Correct Answer: Treat using the reported number now

Self-report is the gold standard for pain assessment, and a score of 6 warrants treatment. Reassessment timing depends on route, generally 15 to 30 minutes after intravenous analgesia to confirm response and identify side effects. Option a is incorrect because delayed reassessment ignores the patient's expressed distress and the observable behavioral cues. That schedule belongs to routine reassessment of a treated patient, not the initial response after a moderate score has been verbalized. Option b is incorrect because overriding a patient's self-report with the nurse's intuition contradicts professional pain management standards. Subjective experience belongs to the patient, and clinical judgment supplements rather than replaces the reported score. Option c is incorrect because vital sign changes are unreliable surrogates for pain, especially in opioid-naive or older clients. Bradycardia or normotension can coexist with severe discomfort, so delaying analgesia until nu

Correct Answer: Hypoventilation preceding desaturation

Elevated end-tidal carbon dioxide with a flattening waveform signals decreased ventilation. Capnography detects this minutes before oxygen saturation drops, especially on supplemental oxygen. The nurse should pause analgesia, stimulate the client, and prepare to support breathing. Option a is incorrect because hyperventilation drives end-tidal carbon dioxide downward into the twenties, not upward into the fifties. A flat waveform with rising values is the exact opposite of the pattern seen during rapid, deep breathing. Option b is incorrect because a malfunctioning sensor would typically produce an absent or erratic waveform rather than a rising end-tidal carbon dioxide value. The reading remains physiologically consistent with retained carbon dioxide from poor ventilation. Option d is incorrect because mild sedation on opioids should keep gas exchange adequate, with end-tidal carbon dioxide between 35 and 45. Crossing 50 is a danger signal that warrants intervention rather than reassu

Correct Answer: Axillary route to bypass restrictions

Diarrhea contraindicates rectal measurement, recent otitis media interferes with tympanic accuracy, and a 4-year-old cannot reliably hold an oral probe. Axillary remains the appropriate noninvasive choice when other routes carry risk or accuracy concerns. Option a is incorrect because diarrhea makes rectal measurement unsafe and uncomfortable. Stool prevents probe contact with mucosa, increases contamination risk, and may trigger further evacuation, so this route should be avoided despite its accuracy. Option b is incorrect because recent middle-ear inflammation distorts tympanic readings and may cause discomfort. The infrared sensor relies on a clear ear canal aimed at the tympanic membrane, which a recovering otitis media patient cannot reliably provide. Option c is incorrect because a 4-year-old typically cannot maintain a closed-mouth seal long enough for an accurate oral reading. Saunders restricts oral thermometry to cooperative children five years and older, ruling out this choi

Correct Answer: Maintain current flow and monitor

An oxygen saturation between 88 and 92 percent is acceptable in chronic carbon dioxide retainers because excess oxygen can suppress the hypoxic drive. The client is comfortable at baseline, so maintaining flow and trending values fits this situation appropriately. Option b is incorrect because pushing oxygen toward 98 percent in a chronic retainer risks suppressing the hypoxic respiratory drive that maintains breathing. This action can precipitate carbon dioxide retention, somnolence, and progressive respiratory failure in this population. Option c is incorrect because a nonrebreather mask delivers very high oxygen concentrations, which would overshoot the acceptable target range. Such aggressive escalation is reserved for severe hypoxia or respiratory failure, neither of which is evident here. Option d is incorrect because abruptly discontinuing oxygen invites desaturation below the acceptable threshold. The 88 to 92 percent target requires ongoing therapy, not removal, since the clie

Correct Answer: Falsely high systolic and diastolic

An undersized cuff requires extra pressure to compress the artery, producing falsely elevated systolic and diastolic values. Bladder width should cover 40 percent of arm circumference and length should encircle 80 percent, so the nurse must locate a larger cuff. Option a is incorrect because an undersized cuff overestimates rather than underestimates pressure. Falsely low values typically occur when the cuff is too large or when the arm is positioned above heart level, neither of which applies here. Option b is incorrect because no amount of careful technique compensates for a poorly fitted cuff. The mechanical mismatch between bladder size and arm circumference distorts readings regardless of stethoscope placement, inflation speed, or deflation rate. Option d is incorrect because both systolic and diastolic numbers shift upward when an inappropriately small cuff is used. Limiting the error to the diastolic measurement misrepresents the way Korotkoff sounds are altered by inadequate ar

Correct Answer: Positive orthostatic hypotension

Criteria for orthostatic hypotension include a systolic drop of at least 20 mmHg, diastolic drop of at least 10 mmHg, or heart rate rise of at least 20 beats per minute within three minutes of standing position. Option b is incorrect because a 24-point systolic drop coupled with a 22-beat heart rate increase exceeds normal compensatory limits. Healthy postural adjustment maintains stable cerebral perfusion, while this client's response signals impaired vasoconstriction or volume depletion. Option c is incorrect because hypertensive emergencies feature systolic pressures above 180 with evidence of target organ damage. The pattern shown reflects falling pressure on standing rather than dangerously elevated readings, so emergency antihypertensives would be inappropriate. Option d is incorrect because the heart rate rose rather than fell, ruling out a vasovagal episode. Reflex bradycardia involves both bradycardia and pallor and sweating, whereas this client demonstrates tachycardia a

Correct Answer: Cushing's triad from rising pressure

Hypertension with widening pulse pressure, bradycardia, and irregular respirations form Cushing's triad, a late sign of increased intracranial pressure. The unequal pupils reinforce the suspicion of impending herniation, so rapid neurosurgical notification is essential immediately. Option a is incorrect because septic shock features hypotension, tachycardia, tachypnea, and often fever or hypothermia. The hypertension and bradycardia pattern is the opposite of the cardiovascular response triggered by overwhelming infection and widespread vasodilation in tissues. Option b is incorrect because anaphylaxis presents with hypotension, tachycardia, urticaria, angioedema, and bronchospasm. None of those features appear in this scenario, and pupil asymmetry is not part of the systemic IgE-mediated reaction pattern. Option c is incorrect because hypovolemic decompensation produces falling pressure with rising heart rate, narrow pulse pressure, cool clammy skin, and oliguria. The findings he

Correct Answer: Total of 8, prepare for intubation

Eye opening to pain scores 2, incomprehensible sounds scores 2, and withdrawal from pain scores 4, for a total of 8. A score at or below 8 warrants airway protection and intubation preparation due to loss of reflexes. Option a is incorrect because a Glasgow Coma Scale of 14 represents near-normal consciousness with minimal confusion. The findings described, including no eye opening to voice and absence of meaningful speech, indicate substantially deeper neurological depression than this score reflects. Option b is incorrect because reaching 11 would require either spontaneous eye opening or confused conversation, neither of which appears in this scenario. The combination of pain-only eye opening with incomprehensible sounds places the client below that threshold. Option d is incorrect because a score of 3 represents complete unresponsiveness with no eye opening, no verbal response, and no motor response. This client opens eyes to pain and withdraws purposefully, demonstrating preserved

Correct Answer: Sudden inspiratory stridor

Among these findings, only stridor signals upper airway obstruction, a true emergency requiring immediate airway evaluation and possible intubation. Stridor demands rapid intervention regardless of underlying disease and takes precedence over expected exacerbation findings like wheezing or accessory muscle use. Option a is incorrect because pursed-lip breathing is an adaptive technique that extends expiration and reduces air trapping. Encouraging the technique aligns with established chronic obstructive pulmonary disease education, so it does not warrant urgent reversal. Option b is incorrect because accessory muscle use signals increased breathing effort but is expected during exacerbations. Treatment with bronchodilators and corticosteroids addresses the underlying obstruction rather than calling for immediate airway rescue maneuvers in this patient. Option c is incorrect because expiratory wheezing in this population reflects lower-airway narrowing that responds to inhaled bronchodi

Correct Answer: Volume overload from heart failure

An S3 gallop in an adult signals rapid ventricular filling against an overdistended chamber, classically associated with heart failure. Combined with jugular venous distention and dependent edema, the picture reflects systemic congestion that warrants diuresis and provider review. Option b is incorrect because an S3 in adults is abnormal even with advancing age. The combination of an abnormal heart sound with congestion findings goes well beyond age-related changes such as a stiffer ventricle or softer first heart sound. Option c is incorrect because cardiac tamponade typically produces muffled heart sounds, hypotension, and pulsus paradoxus, the so-called Beck's triad. The presence of an S3 gallop and dependent edema points away from acute effusion and toward chronic congestion. Option d is incorrect because pulmonary embolism is dominated by sudden dyspnea, pleuritic pain, tachycardia, and hypoxia. Bilateral pitting edema and an apical S3 gallop do not fit the right-heart strain

Correct Answer: Five minutes per quadrant

Absent bowel sounds may be documented only after auscultating each quadrant for a full five minutes. Postoperative ileus is common but should be confirmed thoroughly because mislabeling intermittent activity as absent can drive inappropriate interventions or escalation of care. Option a is incorrect because one minute over the entire abdomen is far too brief to establish absence of bowel sounds. Intermittent activity is missed easily, so the standard requires sustained listening at each quadrant rather than a global pass. Option b is incorrect because two minutes per quadrant captures normal and hyperactive sounds but falls short for confirming absence. The accepted threshold extends to five minutes per quadrant because true silence must outlast typical pauses in motility. Option c is incorrect because ten seconds is appropriate only for a focused screen when sounds are clearly present and active. To rule out absent bowel sounds reliably, the auscultation period must extend across norm

Correct Answer: Rigid abdomen suggesting peritonitis

A rigid, board-like abdomen after biliary surgery raises strong concern for bile leak with peritonitis. Rebound tenderness, fever, and hypotension may follow. The nurse must escalate immediately because untreated peritonitis quickly progresses to septic shock and need for reexploration. Option a is incorrect because referred shoulder pain after laparoscopic or open biliary surgery often reflects residual carbon dioxide irritation of the diaphragm. This is expected and self-limited, contrasting with rigidity that signals true intraperitoneal inflammation requiring action. Option b is incorrect because soft bowel sounds in the lower quadrants are a fairly nonspecific finding that may simply reflect normal slow return of motility. Without other warning signs, they would not be the priority concern in this scenario. Option d is incorrect because minor oozing at incision edges is typically managed with reinforcement of the dressing and continued observation. While worth documenting, this mi

Correct Answer: Output below minimum warrants escalation

Adult urine output must remain at least 30 mL per hour to confirm renal perfusion. A reading of 18 mL signals oliguria, which after surgery raises concern for hypovolemia, bleeding, or acute kidney injury and prompts provider notification. Option b is incorrect because 18 mL falls below the universally accepted minimum of 30 mL per hour for adults. Accepting this volume as normal would delay recognition of hypovolemia, hemorrhage, or impaired renal perfusion that appears in postoperative care. Option c is incorrect because diabetes insipidus drives massive polyuria, often exceeding 200 mL per hour with dilute pale urine. The current reading is the opposite pattern and would not match the high-volume losses characteristic of antidiuretic hormone deficiency. Option d is incorrect because nighttime concentration may slightly reduce urine volume but should not push hourly output below the 30 mL threshold. The reading reflects pathologic oliguria rather than expected diurnal variation in he

Correct Answer: Compartment syndrome of the leg

The five P's of compartment syndrome include pain out of proportion that worsens with passive stretch, pallor, paresthesia, paralysis, and pulselessness. Severe unrelieved pain with passive stretch pain and pallor signals rising intracompartmental pressure requiring urgent fasciotomy evaluation now. Option a is incorrect because expected postoperative pain responds to scheduled opioid analgesia and improves with rest and elevation. Pain that escalates beyond opioid coverage and worsens with passive stretch represents pathology, not the recovery trajectory of orthopedic surgery. Option b is incorrect because cast-related wound infection typically presents with fever, foul drainage, warmth, and a sweetish odor under the cast. The dominant feature here is severe ischemic-type pain with pallor, pointing to a vascular emergency. Option d is incorrect because deep vein thrombosis usually produces calf swelling, warmth, and aching pain rather than pallor or pain worsened by passive toe s

Correct Answer: Activate rapid response, notify provider

Multiple parameters in the elevated scoring range produce a total well above the four-point threshold for escalation. Hypotension, tachycardia, tachypnea, fever, and decreased responsiveness collectively signal early deterioration that benefits from rapid response activation and physician evaluation. Option a is incorrect because a Modified Early Warning Score in the escalation range requires acceleration rather than a return to routine timing. Stretching the next assessment to four hours risks missing the inflection point at which intervention reverses deterioration. Option c is incorrect because the cluster of abnormal parameters described will not resolve simply with rest. The pattern raises strong concern for sepsis or hypovolemia, and waiting silently for spontaneous improvement abandons the window where action prevents harm. Option d is incorrect because administering scheduled medications without addressing the deteriorating picture overlooks the urgency of the moment. Some of t

Correct Answer: Possible sepsis warranting prompt evaluation

qSOFA flags two or more of these criteria: altered mentation, systolic pressure at or below 100, or respiratory rate at or above 22. All three are met here with suspected infection, raising sepsis concern and triggering early bundle initiation. Option b is incorrect because positive qSOFA criteria in a patient with suspected infection identify rising sepsis risk, not stability. Treating this picture as benign delays cultures, antibiotics, and fluid resuscitation that change outcomes when started within the first hour. Option c is incorrect because altered mentation, borderline pressure, and tachypnea indicate that compensation is already strained. These markers track with organ dysfunction rather than reserve, and a falsely reassuring interpretation can defer life-saving treatment. Option d is incorrect because qSOFA was developed precisely to flag infected patients at higher risk of poor outcomes. Dismissing the findings as unrelated misses the bedside screening tool's intended u

Correct Answer: Cultures, lactate, antibiotics, fluids, pressors

The hour-one bundle includes measuring lactate, drawing blood cultures before antibiotics, administering broad-spectrum antibiotics, beginning 30 mL per kilogram crystalloid for hypotension or elevated lactate, and starting vasopressors if hypotension persists during or after fluid resuscitation. Option a is incorrect because giving antibiotics before drawing cultures lowers culture yield and may obscure the causative organism. Cultures must precede antimicrobial administration whenever possible to preserve diagnostic accuracy and guide targeted therapy later. Option c is incorrect because vasopressors are reserved for hypotension that persists during or after adequate fluid resuscitation. Starting vasoactive infusions before volume repletion can worsen end-organ perfusion and obscure the response to initial crystalloid administration. Option d is incorrect because waiting six hours abandons the critical first-hour window when source control, antibiotics, and fluids change mortality ou

Correct Answer: Vital sign trend and exam findings

Assessment in SBAR conveys the nurse's clinical interpretation: vital sign trends, focused exam findings, and an impression of what may be happening. Recommendation then proposes specific actions such as a bedside visit, additional orders, or transfer of care. Option a is incorrect because requested orders belong in the recommendation step, which follows assessment. Mixing them in earlier weakens the structure that helps the provider understand the picture before deciding what to order or change. Option b is incorrect because medication scheduling represents routine background information rather than the clinical synthesis assessment provides. The provider needs a current interpretation of what is changing, not the planned timing of an ongoing medication regimen. Option d is incorrect because social and family relationships rarely fit the SBAR assessment step during deterioration calls. These details are valuable for psychosocial planning but distract from the time-sensitive clini

Correct Answer: Neutropenic protective precautions throughout care

An absolute neutrophil count below 500 defines severe neutropenia and triggers protective isolation. This includes a private room, strict hand hygiene, no fresh flowers or raw produce, and limiting visitors with active infections to reduce opportunistic exposure risk. Option a is incorrect because contact precautions are designed to limit transmission of organisms such as Clostridioides difficile or methicillin-resistant Staphylococcus aureus from the patient. They do not protect a vulnerable host from environmental and visitor-borne organisms. Option b is incorrect because standard precautions alone leave an immunocompromised host exposed to ambient organisms. Severe neutropenia requires additional protective measures that exceed the universal baseline used for every patient regardless of immune status. Option c is incorrect because droplet precautions target respiratory pathogens spread by large particles. They are oriented toward containing infection from a patient, not toward prote