2026/2027 HESI EXIT EXAM V5 | NGN CASE STUDIES & 160 Q&A PDF
HESI RN Exit Examination Version 5 (V5) with Next Generation NCLEX® (NGN) Comprehensive Case
Studies & Question Bank | Core Domains: Advanced Clinical Judgment via NGN Items (Matrix,
Bow-Tie, Extended Multiple Response, Cloze), Complex Multisystem Unfolding Case Studies, Integrated
Advanced Pharmacology & Pathophysiology, Emergency & Critical Care Prioritization, Health
Promotion & Chronic Disease Management Across the Lifespan, Interprofessional Collaboration &
Communication in Complex Cases, and Ethical/Legal Analysis in Dynamic Clinical Scenarios |
NCLEX-RN® Readiness Focus | Comprehensive Case-Based PDF Exam Bank Format
Exam Structure
The HESI Exit Exam V5 with NGN for the 2026/2027 academic cycle is a 160-question, multiple-choice
question (MCQ) and NGN item-type examination.
Introduction
This HESI Exit Exam V5 NGN Q&A PDF for the 2026/2027 cycle provides an extensive, high-fidelity
question bank featuring advanced case studies fully aligned with the Next Generation NCLEX®
framework. Designed for superior preparation, it challenges students with complex, evolving patient
scenarios requiring synthesis of advanced nursing knowledge, sophisticated clinical judgment, and
evidence-based decision-making to ensure elite performance on the updated NCLEX-RN® examination.
Answer Format
All correct answers and advanced clinical judgments must be presented in bold and green, followed by
detailed rationales that systematically apply the NGN Clinical Judgment Measurement Model, integrate
complex pathophysiology and advanced pharmacology, justify priority interventions in high-acuity and
chronic care scenarios, analyze interprofessional team dynamics, and evaluate patient outcomes in
sophisticated, unfolding case studies.
Questions (160 Total)
1.
A 78-year-old male with heart failure (HFrEF, EF 18%), CKD stage 4 (eGFR 22 mL/min), and atrial
fibrillation (CHA₂DS₂-VASc = 6) presents with acute pulmonary edema: BP 202/110 mm Hg, HR 138 bpm
(irregular), RR 38/min, SpO₂ 80% on room air, bilateral crackles to apices. He takes furosemide 80 mg
BID and lisinopril at home. Labs: K⁺ 2.9 mEq/L, BNP 920 pg/mL, INR 1.0.
Which action should the nurse take first?
A. Administer furosemide 80 mg IV
B. Apply high-flow oxygen via non-rebreather mask and elevate head of bed to 90°
,C. Start nitroglycerin IV infusion
D. Give potassium chloride 40 mEq IV
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Severe hypoxia (SpO₂ 80%), tachypnea, crackles to apices = life-threatening
respiratory failure.
Analyze Cues: Without immediate oxygenation, other interventions (diuresis, vasodilation) will fail.
Hypokalemia is critical but secondary to oxygenation.
Prioritize Hypotheses: Inadequate oxygenation > fluid overload > electrolyte imbalance >
anticoagulation need.
Generate Solutions: Maximize O₂ delivery before pharmacologic intervention.
Take Action: Non-rebreather provides up to 90% FiO₂; 90° position reduces venous return and
pulmonary congestion.
Evaluate Outcomes: SpO₂ improves within 1–2 minutes; work of breathing decreases.
2.
A 3-day-old newborn with ABO incompatibility has total serum bilirubin of 20.2 mg/dL despite 36 hours
of intensive phototherapy. The infant is lethargic, feeding poorly, and has a high-pitched cry. Blood type:
mother O+, baby A+.
What is the priority intervention?
A. Continue phototherapy and recheck bilirubin in 1 hour
B. Prepare for immediate exchange transfusion
C. Administer IV immunoglobulin (IVIG) 1 g/kg IV
D. Increase IV hydration with D10W at 150 mL/kg/day
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Bilirubin >20 in a 3-day-old + neurological symptoms (lethargy, high-pitched cry).
Analyze Cues: These are signs of acute bilirubin encephalopathy—precursor to kernicterus.
Prioritize Hypotheses: Permanent neurological damage is imminent without rapid intervention.
,Generate Solutions: Exchange transfusion removes bilirubin and maternal antibodies faster than
IVIG alone.
Take Action: Notify neonatologist STAT; obtain consent; ensure type-specific blood is available.
Evaluate Outcomes: Bilirubin declines rapidly; neurological symptoms resolve without sequelae.
3.
A 55-year-old female with bipolar I disorder is admitted after a manic episode. She is agitated, shouting
delusions of grandeur (“I’m the CEO of the universe!”), and attempting to leave AMA. Lithium level is 0.1
mEq/L. Security is called due to escalating aggression toward staff.
What is the nurse’s best initial action?
A. Apply physical restraints immediately
B. Use verbal de-escalation, offer PRN lorazepam 2 mg PO, and involve psychiatrist for
capacity assessment
C. Administer IM haloperidol 5 mg without consent
D. Discharge her to avoid liability
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Mania, agitation, delusions, low lithium, AMA attempt, aggression.
Analyze Cues: Restraints are last resort; least restrictive intervention preserves trust and safety.
Prioritize Hypotheses: Safety through engagement > coercion.
Generate Solutions: Calm tone, clear boundaries, offer anxiolytic, assess decisional capacity.
Take Action: “I’m here to keep you safe. Can we talk about what’s upsetting you?”
Evaluate Outcomes: Agitation decreases; patient agrees to stay for treatment.
4.
An 85-year-old Indigenous elder with end-stage renal disease refuses dialysis, stating, “My spirit is ready
to join my ancestors.” Family requests traditional smudging with sage during care. Hospital policy
prohibits open flames in patient rooms due to oxygen use.
What should the nurse do?
, A. Deny request due to fire code
B. Collaborate with family, chaplain, and risk management to implement smokeless
smudging protocol using fan and loose sage
C. Allow smudging when staff are off-unit
D. Document refusal of cultural care
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Spiritual/cultural request, safety policy conflict, end-of-life context, oxygen therapy.
Analyze Cues: Cultural humility requires balancing respect with institutional safety.
Prioritize Hypotheses: Honor patient autonomy and cultural identity while preventing fire hazard.
Generate Solutions: Many hospitals now approve smokeless alternatives (fan-assisted smudging).
Take Action: Facilitate interdisciplinary meeting with family, chaplain, and safety officer.
Evaluate Outcomes: Ritual performed safely; family reports dignity in dying.
5.
A 9-year-old with status asthmaticus has SpO₂ 76% on 15 L/min O₂ via non-rebreather, RR 62/min, HR
172 bpm, and silent chest. Continuous albuterol, ipratropium, IV methylprednisolone, and magnesium
sulfate were started 60 minutes ago with no improvement.
What is the priority action?
A. Administer another dose of magnesium sulfate IV
B. Call rapid response and prepare for emergency intubation
C. Obtain ABG and lactate
D. Encourage incentive spirometry every hour
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Silent chest = no air movement = respiratory arrest imminent.
Analyze Cues: Exhaustion has occurred; maximal medical therapy is failing.
Prioritize Hypotheses: Airway protection is immediately life-saving.
HESI RN Exit Examination Version 5 (V5) with Next Generation NCLEX® (NGN) Comprehensive Case
Studies & Question Bank | Core Domains: Advanced Clinical Judgment via NGN Items (Matrix,
Bow-Tie, Extended Multiple Response, Cloze), Complex Multisystem Unfolding Case Studies, Integrated
Advanced Pharmacology & Pathophysiology, Emergency & Critical Care Prioritization, Health
Promotion & Chronic Disease Management Across the Lifespan, Interprofessional Collaboration &
Communication in Complex Cases, and Ethical/Legal Analysis in Dynamic Clinical Scenarios |
NCLEX-RN® Readiness Focus | Comprehensive Case-Based PDF Exam Bank Format
Exam Structure
The HESI Exit Exam V5 with NGN for the 2026/2027 academic cycle is a 160-question, multiple-choice
question (MCQ) and NGN item-type examination.
Introduction
This HESI Exit Exam V5 NGN Q&A PDF for the 2026/2027 cycle provides an extensive, high-fidelity
question bank featuring advanced case studies fully aligned with the Next Generation NCLEX®
framework. Designed for superior preparation, it challenges students with complex, evolving patient
scenarios requiring synthesis of advanced nursing knowledge, sophisticated clinical judgment, and
evidence-based decision-making to ensure elite performance on the updated NCLEX-RN® examination.
Answer Format
All correct answers and advanced clinical judgments must be presented in bold and green, followed by
detailed rationales that systematically apply the NGN Clinical Judgment Measurement Model, integrate
complex pathophysiology and advanced pharmacology, justify priority interventions in high-acuity and
chronic care scenarios, analyze interprofessional team dynamics, and evaluate patient outcomes in
sophisticated, unfolding case studies.
Questions (160 Total)
1.
A 78-year-old male with heart failure (HFrEF, EF 18%), CKD stage 4 (eGFR 22 mL/min), and atrial
fibrillation (CHA₂DS₂-VASc = 6) presents with acute pulmonary edema: BP 202/110 mm Hg, HR 138 bpm
(irregular), RR 38/min, SpO₂ 80% on room air, bilateral crackles to apices. He takes furosemide 80 mg
BID and lisinopril at home. Labs: K⁺ 2.9 mEq/L, BNP 920 pg/mL, INR 1.0.
Which action should the nurse take first?
A. Administer furosemide 80 mg IV
B. Apply high-flow oxygen via non-rebreather mask and elevate head of bed to 90°
,C. Start nitroglycerin IV infusion
D. Give potassium chloride 40 mEq IV
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Severe hypoxia (SpO₂ 80%), tachypnea, crackles to apices = life-threatening
respiratory failure.
Analyze Cues: Without immediate oxygenation, other interventions (diuresis, vasodilation) will fail.
Hypokalemia is critical but secondary to oxygenation.
Prioritize Hypotheses: Inadequate oxygenation > fluid overload > electrolyte imbalance >
anticoagulation need.
Generate Solutions: Maximize O₂ delivery before pharmacologic intervention.
Take Action: Non-rebreather provides up to 90% FiO₂; 90° position reduces venous return and
pulmonary congestion.
Evaluate Outcomes: SpO₂ improves within 1–2 minutes; work of breathing decreases.
2.
A 3-day-old newborn with ABO incompatibility has total serum bilirubin of 20.2 mg/dL despite 36 hours
of intensive phototherapy. The infant is lethargic, feeding poorly, and has a high-pitched cry. Blood type:
mother O+, baby A+.
What is the priority intervention?
A. Continue phototherapy and recheck bilirubin in 1 hour
B. Prepare for immediate exchange transfusion
C. Administer IV immunoglobulin (IVIG) 1 g/kg IV
D. Increase IV hydration with D10W at 150 mL/kg/day
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Bilirubin >20 in a 3-day-old + neurological symptoms (lethargy, high-pitched cry).
Analyze Cues: These are signs of acute bilirubin encephalopathy—precursor to kernicterus.
Prioritize Hypotheses: Permanent neurological damage is imminent without rapid intervention.
,Generate Solutions: Exchange transfusion removes bilirubin and maternal antibodies faster than
IVIG alone.
Take Action: Notify neonatologist STAT; obtain consent; ensure type-specific blood is available.
Evaluate Outcomes: Bilirubin declines rapidly; neurological symptoms resolve without sequelae.
3.
A 55-year-old female with bipolar I disorder is admitted after a manic episode. She is agitated, shouting
delusions of grandeur (“I’m the CEO of the universe!”), and attempting to leave AMA. Lithium level is 0.1
mEq/L. Security is called due to escalating aggression toward staff.
What is the nurse’s best initial action?
A. Apply physical restraints immediately
B. Use verbal de-escalation, offer PRN lorazepam 2 mg PO, and involve psychiatrist for
capacity assessment
C. Administer IM haloperidol 5 mg without consent
D. Discharge her to avoid liability
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Mania, agitation, delusions, low lithium, AMA attempt, aggression.
Analyze Cues: Restraints are last resort; least restrictive intervention preserves trust and safety.
Prioritize Hypotheses: Safety through engagement > coercion.
Generate Solutions: Calm tone, clear boundaries, offer anxiolytic, assess decisional capacity.
Take Action: “I’m here to keep you safe. Can we talk about what’s upsetting you?”
Evaluate Outcomes: Agitation decreases; patient agrees to stay for treatment.
4.
An 85-year-old Indigenous elder with end-stage renal disease refuses dialysis, stating, “My spirit is ready
to join my ancestors.” Family requests traditional smudging with sage during care. Hospital policy
prohibits open flames in patient rooms due to oxygen use.
What should the nurse do?
, A. Deny request due to fire code
B. Collaborate with family, chaplain, and risk management to implement smokeless
smudging protocol using fan and loose sage
C. Allow smudging when staff are off-unit
D. Document refusal of cultural care
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Spiritual/cultural request, safety policy conflict, end-of-life context, oxygen therapy.
Analyze Cues: Cultural humility requires balancing respect with institutional safety.
Prioritize Hypotheses: Honor patient autonomy and cultural identity while preventing fire hazard.
Generate Solutions: Many hospitals now approve smokeless alternatives (fan-assisted smudging).
Take Action: Facilitate interdisciplinary meeting with family, chaplain, and safety officer.
Evaluate Outcomes: Ritual performed safely; family reports dignity in dying.
5.
A 9-year-old with status asthmaticus has SpO₂ 76% on 15 L/min O₂ via non-rebreather, RR 62/min, HR
172 bpm, and silent chest. Continuous albuterol, ipratropium, IV methylprednisolone, and magnesium
sulfate were started 60 minutes ago with no improvement.
What is the priority action?
A. Administer another dose of magnesium sulfate IV
B. Call rapid response and prepare for emergency intubation
C. Obtain ABG and lactate
D. Encourage incentive spirometry every hour
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Silent chest = no air movement = respiratory arrest imminent.
Analyze Cues: Exhaustion has occurred; maximal medical therapy is failing.
Prioritize Hypotheses: Airway protection is immediately life-saving.
