HESI RN Exit Exam Actual Exam 2026/2027 |
Questions with Verified Answers | 100%
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SECTION 1: Fundamentals & Safe Care
Q1: A 78-year-old client with a Foley catheter post-stroke is found with cloudy urine and a temperature of
38.1 °C. Which action is the nurse’s priority?
A. Increase oral fluid intake
B. Obtain a urine culture from the collection bag port
C. Notify the provider immediately
D. Document findings and reassess in 4 h
Correct Answer: B
Rationale: Cloudy urine + fever suggests CAUTI. Per CDC guidelines, obtaining a culture before
antibiotics is priority (Assessment). Option A is premature without orders. Option C is secondary to
culture collection. Option D delays necessary intervention.
Q2: During shift report, a nurse learns a client’s INR is 4.8 (therapeutic 2–3). The client has epistaxis and
gums oozing blood. Which intervention is most urgent?
A. Apply ice to the nose and continue current warfarin dose
B. Hold the next warfarin dose and notify the provider stat
C. Administer vitamin K orally as prescribed
D. Start an IV of 0.9% saline at 125 mL/hr
Correct Answer: B
Rationale: INR above therapeutic with bleeding = hold warfarin (Implementation). Option A continues an
unsafe dose. Option C is provider-ordered, not nurse-initiated. Option D does not address anticoagulation.
Q3: A newly admitted client has a Braden scale score of 12. Which nursing action is best to prevent
pressure injury?
A. Reposition every 4 h
B. Apply heel protectors and use a low-air-loss mattress
C. Offer a high-protein snack twice daily
D. Massage bony prominences during bathing
Correct Answer: B
Rationale: Score ≤12 = high risk; off-loading devices are evidence-based (Planning). Option A interval is
too long. Option C helps but is secondary. Option D causes shear (unsafe).
Q4: A nurse witnesses a UAP (unlicensed assistive personnel) entering a isolation room without gown or
gloves. The client has C. difficile. The nurse’s first action is to:
A. Report the UAP to the charge nurse
B. Immediately stop the UAP and provide teaching
C. Document the incident in the UAP file
D. Complete an incident report after shift
,Correct Answer: B
Rationale: Immediate safety overrides administrative steps (Implementation). Options A, C, D are
appropriate after stopping the breach.
Q5: While assessing a post-op client, the nurse notes a pulse oximeter reading of 89%, but the client
appears comfortable. Which action is priority?
A. Recheck probe placement and obtain a manual blood pressure
B. Apply oxygen 2 L via nasal cannula and reassess in 15 min
C. Encourage deep breathing and coughing
D. Document the reading as normal for post-op
Correct Answer: A
Rationale: Verify accuracy first (Assessment); artifact is common. Option B is premature without
confirming hypoxemia. Option C is useful only if confirmed. Option D is unsafe.
Q6: A client on contact precautions for MRSA asks why visitors wear gowns. The nurse’s best response
is:
A. “It prevents you from catching other germs.”
B. “It protects staff and visitors from spreading MRSA.”
C. “It’s hospital policy for everyone.”
D. “It keeps your room clean.”
Correct Answer: B
Rationale: Patient-centered education explains transmission-based precautions (Evaluation). Option A is
incorrect (reverse). Option C is vague. Option D is irrelevant.
Q7: A nurse is preparing to insert an IV. Which action best demonstrates surgical asepsis?
A. Washing hands for 15 seconds
B. Using sterile gloves and 2% chlorhexidine swab
C. Wearing clean gloves and using alcohol wipe
D. Keeping the catheter package sealed until use
Correct Answer: B
Rationale: Surgical asepsis requires sterile technique (Implementation). Option A is hand hygiene. Option
C is clean technique. Option D is storage, not technique.
Q8: A client’s bedside monitor alarms with asystole. The nurse notes the client is talking. Which action is
priority?
A. Call the code team immediately
B. Check lead placement and electrode contact
C. Begin chest compressions
D. Defibrillate at 200 J
Correct Answer: B
Rationale: Artifact is likely; assess first (Assessment). Options A, C, D are unsafe without confirming
cardiac arrest.
Q9: A nurse is giving shift report using SBAR. Which component is missing if the nurse states: “The
client had 2,000 mL output and 1,800 mL intake, BP stable”?
A. Situation
B. Background
C. Assessment
D. Recommendation
, Correct Answer: D
Rationale: Recommendation (e.g., “Monitor for fluid overload”) is absent (Evaluation). Other components
are implied.
Q10: A client’s restraint is renewed every 4 h per order. Which assessment finding requires immediate
removal?
A. Peripheral IV infiltrated in restrained arm
B. Client is sleepy but arousable
C. Skin intact, capillary refill <3 s
D. Client states, “I need to use the bathroom.”
Correct Answer: A
Rationale: Circulatory compromise is an emergency (Assessment). Other options are expected or
manageable.
Q11: A client is receiving warfarin 5 mg PO daily. The INR is 5.5 (target 2–3). Which medication might
have contributed?
A. Acetaminophen 650 mg q6h PRN
B. Omeprazole 20 mg daily
C. Metoprolol 50 mg BID
D. Albuterol inhaler q4h PRN
Correct Answer: A
Rationale: Acetaminophen >2 g/day increases INR (Analysis). Other drugs have minimal anticoagulant
effect.
Q12: A post-op client has a morphine PCA. The nurse notes respiratory rate 8/min, SpO₂ 86%. Which
PRN medication should the nurse prepare?
A. Naloxone 0.4 mg IV
B. Flumazenil 0.5 mg IV
C. Atropine 0.5 mg IV
D. Epinephrine 0.5 mg IM
Correct Answer: A
Rationale: Opioid-induced respiratory depression → naloxone (Implementation). Other agents are
ineffective for opioids.
Q13: A nursing student asks why two patient identifiers are needed before medication administration. The
best response is:
A. “It’s a Joint Commission requirement.”
B. “It prevents medication errors and ensures safety.”
C. “It speeds up the process.”
D. “It satisfies the hospital policy.”
Correct Answer: B
Rationale: Patient safety is the underlying reason (Evaluation). Option A is correct but superficial.
Options C, D are incorrect.
SECTION 2: Adult Medical-Surgical Nursing
Q14: A 65-year-old post-MI client has new-onset confusion and fine crackles bilaterally. BNP is 1,200
pg/mL. Which order is priority?
A. Schedule echocardiogram in AM
B. Administer furosemide 40 mg IV push now
Questions with Verified Answers | 100%
Correct | Pass Guaranteed
SECTION 1: Fundamentals & Safe Care
Q1: A 78-year-old client with a Foley catheter post-stroke is found with cloudy urine and a temperature of
38.1 °C. Which action is the nurse’s priority?
A. Increase oral fluid intake
B. Obtain a urine culture from the collection bag port
C. Notify the provider immediately
D. Document findings and reassess in 4 h
Correct Answer: B
Rationale: Cloudy urine + fever suggests CAUTI. Per CDC guidelines, obtaining a culture before
antibiotics is priority (Assessment). Option A is premature without orders. Option C is secondary to
culture collection. Option D delays necessary intervention.
Q2: During shift report, a nurse learns a client’s INR is 4.8 (therapeutic 2–3). The client has epistaxis and
gums oozing blood. Which intervention is most urgent?
A. Apply ice to the nose and continue current warfarin dose
B. Hold the next warfarin dose and notify the provider stat
C. Administer vitamin K orally as prescribed
D. Start an IV of 0.9% saline at 125 mL/hr
Correct Answer: B
Rationale: INR above therapeutic with bleeding = hold warfarin (Implementation). Option A continues an
unsafe dose. Option C is provider-ordered, not nurse-initiated. Option D does not address anticoagulation.
Q3: A newly admitted client has a Braden scale score of 12. Which nursing action is best to prevent
pressure injury?
A. Reposition every 4 h
B. Apply heel protectors and use a low-air-loss mattress
C. Offer a high-protein snack twice daily
D. Massage bony prominences during bathing
Correct Answer: B
Rationale: Score ≤12 = high risk; off-loading devices are evidence-based (Planning). Option A interval is
too long. Option C helps but is secondary. Option D causes shear (unsafe).
Q4: A nurse witnesses a UAP (unlicensed assistive personnel) entering a isolation room without gown or
gloves. The client has C. difficile. The nurse’s first action is to:
A. Report the UAP to the charge nurse
B. Immediately stop the UAP and provide teaching
C. Document the incident in the UAP file
D. Complete an incident report after shift
,Correct Answer: B
Rationale: Immediate safety overrides administrative steps (Implementation). Options A, C, D are
appropriate after stopping the breach.
Q5: While assessing a post-op client, the nurse notes a pulse oximeter reading of 89%, but the client
appears comfortable. Which action is priority?
A. Recheck probe placement and obtain a manual blood pressure
B. Apply oxygen 2 L via nasal cannula and reassess in 15 min
C. Encourage deep breathing and coughing
D. Document the reading as normal for post-op
Correct Answer: A
Rationale: Verify accuracy first (Assessment); artifact is common. Option B is premature without
confirming hypoxemia. Option C is useful only if confirmed. Option D is unsafe.
Q6: A client on contact precautions for MRSA asks why visitors wear gowns. The nurse’s best response
is:
A. “It prevents you from catching other germs.”
B. “It protects staff and visitors from spreading MRSA.”
C. “It’s hospital policy for everyone.”
D. “It keeps your room clean.”
Correct Answer: B
Rationale: Patient-centered education explains transmission-based precautions (Evaluation). Option A is
incorrect (reverse). Option C is vague. Option D is irrelevant.
Q7: A nurse is preparing to insert an IV. Which action best demonstrates surgical asepsis?
A. Washing hands for 15 seconds
B. Using sterile gloves and 2% chlorhexidine swab
C. Wearing clean gloves and using alcohol wipe
D. Keeping the catheter package sealed until use
Correct Answer: B
Rationale: Surgical asepsis requires sterile technique (Implementation). Option A is hand hygiene. Option
C is clean technique. Option D is storage, not technique.
Q8: A client’s bedside monitor alarms with asystole. The nurse notes the client is talking. Which action is
priority?
A. Call the code team immediately
B. Check lead placement and electrode contact
C. Begin chest compressions
D. Defibrillate at 200 J
Correct Answer: B
Rationale: Artifact is likely; assess first (Assessment). Options A, C, D are unsafe without confirming
cardiac arrest.
Q9: A nurse is giving shift report using SBAR. Which component is missing if the nurse states: “The
client had 2,000 mL output and 1,800 mL intake, BP stable”?
A. Situation
B. Background
C. Assessment
D. Recommendation
, Correct Answer: D
Rationale: Recommendation (e.g., “Monitor for fluid overload”) is absent (Evaluation). Other components
are implied.
Q10: A client’s restraint is renewed every 4 h per order. Which assessment finding requires immediate
removal?
A. Peripheral IV infiltrated in restrained arm
B. Client is sleepy but arousable
C. Skin intact, capillary refill <3 s
D. Client states, “I need to use the bathroom.”
Correct Answer: A
Rationale: Circulatory compromise is an emergency (Assessment). Other options are expected or
manageable.
Q11: A client is receiving warfarin 5 mg PO daily. The INR is 5.5 (target 2–3). Which medication might
have contributed?
A. Acetaminophen 650 mg q6h PRN
B. Omeprazole 20 mg daily
C. Metoprolol 50 mg BID
D. Albuterol inhaler q4h PRN
Correct Answer: A
Rationale: Acetaminophen >2 g/day increases INR (Analysis). Other drugs have minimal anticoagulant
effect.
Q12: A post-op client has a morphine PCA. The nurse notes respiratory rate 8/min, SpO₂ 86%. Which
PRN medication should the nurse prepare?
A. Naloxone 0.4 mg IV
B. Flumazenil 0.5 mg IV
C. Atropine 0.5 mg IV
D. Epinephrine 0.5 mg IM
Correct Answer: A
Rationale: Opioid-induced respiratory depression → naloxone (Implementation). Other agents are
ineffective for opioids.
Q13: A nursing student asks why two patient identifiers are needed before medication administration. The
best response is:
A. “It’s a Joint Commission requirement.”
B. “It prevents medication errors and ensures safety.”
C. “It speeds up the process.”
D. “It satisfies the hospital policy.”
Correct Answer: B
Rationale: Patient safety is the underlying reason (Evaluation). Option A is correct but superficial.
Options C, D are incorrect.
SECTION 2: Adult Medical-Surgical Nursing
Q14: A 65-year-old post-MI client has new-onset confusion and fine crackles bilaterally. BNP is 1,200
pg/mL. Which order is priority?
A. Schedule echocardiogram in AM
B. Administer furosemide 40 mg IV push now
