PN HESI EXIT REAL EXAM: Practice
Questions with Answers, Evidence-
Based Rationales, and Nursing
Interventions - Comprehensive
Review for Practical Nursing Licensure
Fundamentals of Nursing & Safety
Question 1
The PN is preparing to ambulate a postoperative client after cardiac
surgery. Which action will best enable the client to tolerate the
ambulation?
A) Provide the client with a walker.
B) Remove telemetry equipment.
C) Encourage coughing and deep breathing.
D) Premedicate the client with an analgesic before ambulating.
Answer: D) Premedicate the client with an analgesic before
ambulating.
Rationale: Pain management is essential before activity in postoperative
clients. Administering an analgesic 30-60 minutes before ambulation helps
,reduce pain, allowing the client to participate more effectively in the activity
and tolerate it better. A walker may be helpful but does not address pain.
Telemetry should remain in place during ambulation for cardiac monitoring.
Coughing and deep breathing are important but are separate interventions
for preventing respiratory complications.
Question 2
A client is wearing a continuous cardiac monitor, which begins to
alarm at the nurse's station. The nurse sees no electrocardiographic
complexes on the screen. What should the PN do first?
A) Call a code blue.
B) Call the healthcare provider.
C) Check the client status and lead placement.
D) Press the recorder button on the ECG console.
Answer: C) Check the client status and lead placement.
Rationale: The first action is to assess the client and verify equipment
function. A flat line on the monitor may indicate lead disconnection, loose
electrodes, or client movement rather than cardiac arrest. The PN should
check the client's pulse and consciousness while also checking lead
placement. Calling a code blue or the healthcare provider without assessing
the client is premature. Pressing the recorder button does not address the
immediate concern.
,Question 3
A client with heart failure suddenly develops extreme dyspnea,
tachycardia, and lung crackles. The nurse suspects pulmonary edema.
Which interventions should the PN expect to be prescribed? Select all
that apply.
A) Administering oxygen
B) Inserting a Foley catheter
C) Administering furosemide (Lasix)
D) Administering morphine sulfate intravenously
E) Positioning the client flat
Answer: A, B, C, D
Rationale: Pulmonary edema is a life-threatening emergency requiring
immediate intervention. Oxygen administration improves oxygenation. A
Foley catheter is inserted to monitor urine output and assess response to
diuretics. Furosemide (Lasix) is a loop diuretic that reduces fluid volume
overload. Morphine sulfate reduces preload and anxiety, and helps
decrease pulmonary congestion. The client should be positioned in high
Fowler's position to facilitate breathing, not flat.
Question 4
, The PN is providing oral care for an unconscious client. Which action is
most important to prevent aspiration?
A) Position the client on the side.
B) Use a toothbrush to brush the teeth.
C) Use glycerin swabs to clean the mouth.
D) Apply petroleum jelly to the lips.
Answer: A) Position the client on the side.
Rationale: Positioning the unconscious client on the side (lateral position)
is the most important action to prevent aspiration of fluids during oral care.
This position allows fluids to drain from the mouth rather than pooling in
the pharynx and entering the airway. Glycerin swabs can be drying and are
not recommended for routine oral care. Petroleum jelly can be applied after
oral care to prevent drying. The PN should also suction secretions as
needed and provide oral care at least every 2 hours.
Question 5
Which client is at highest risk for falls?
A) A 65-year-old client with hypertension
B) A 70-year-old client with diabetic neuropathy
C) A 75-year-old client with osteoarthritis
D) An 80-year-old client with dementia
Questions with Answers, Evidence-
Based Rationales, and Nursing
Interventions - Comprehensive
Review for Practical Nursing Licensure
Fundamentals of Nursing & Safety
Question 1
The PN is preparing to ambulate a postoperative client after cardiac
surgery. Which action will best enable the client to tolerate the
ambulation?
A) Provide the client with a walker.
B) Remove telemetry equipment.
C) Encourage coughing and deep breathing.
D) Premedicate the client with an analgesic before ambulating.
Answer: D) Premedicate the client with an analgesic before
ambulating.
Rationale: Pain management is essential before activity in postoperative
clients. Administering an analgesic 30-60 minutes before ambulation helps
,reduce pain, allowing the client to participate more effectively in the activity
and tolerate it better. A walker may be helpful but does not address pain.
Telemetry should remain in place during ambulation for cardiac monitoring.
Coughing and deep breathing are important but are separate interventions
for preventing respiratory complications.
Question 2
A client is wearing a continuous cardiac monitor, which begins to
alarm at the nurse's station. The nurse sees no electrocardiographic
complexes on the screen. What should the PN do first?
A) Call a code blue.
B) Call the healthcare provider.
C) Check the client status and lead placement.
D) Press the recorder button on the ECG console.
Answer: C) Check the client status and lead placement.
Rationale: The first action is to assess the client and verify equipment
function. A flat line on the monitor may indicate lead disconnection, loose
electrodes, or client movement rather than cardiac arrest. The PN should
check the client's pulse and consciousness while also checking lead
placement. Calling a code blue or the healthcare provider without assessing
the client is premature. Pressing the recorder button does not address the
immediate concern.
,Question 3
A client with heart failure suddenly develops extreme dyspnea,
tachycardia, and lung crackles. The nurse suspects pulmonary edema.
Which interventions should the PN expect to be prescribed? Select all
that apply.
A) Administering oxygen
B) Inserting a Foley catheter
C) Administering furosemide (Lasix)
D) Administering morphine sulfate intravenously
E) Positioning the client flat
Answer: A, B, C, D
Rationale: Pulmonary edema is a life-threatening emergency requiring
immediate intervention. Oxygen administration improves oxygenation. A
Foley catheter is inserted to monitor urine output and assess response to
diuretics. Furosemide (Lasix) is a loop diuretic that reduces fluid volume
overload. Morphine sulfate reduces preload and anxiety, and helps
decrease pulmonary congestion. The client should be positioned in high
Fowler's position to facilitate breathing, not flat.
Question 4
, The PN is providing oral care for an unconscious client. Which action is
most important to prevent aspiration?
A) Position the client on the side.
B) Use a toothbrush to brush the teeth.
C) Use glycerin swabs to clean the mouth.
D) Apply petroleum jelly to the lips.
Answer: A) Position the client on the side.
Rationale: Positioning the unconscious client on the side (lateral position)
is the most important action to prevent aspiration of fluids during oral care.
This position allows fluids to drain from the mouth rather than pooling in
the pharynx and entering the airway. Glycerin swabs can be drying and are
not recommended for routine oral care. Petroleum jelly can be applied after
oral care to prevent drying. The PN should also suction secretions as
needed and provide oral care at least every 2 hours.
Question 5
Which client is at highest risk for falls?
A) A 65-year-old client with hypertension
B) A 70-year-old client with diabetic neuropathy
C) A 75-year-old client with osteoarthritis
D) An 80-year-old client with dementia
