EXAM FOR HESI RN Exit 2026–2027
HESI RN Exit 2026–2027 • Premium Word-Stable Edition | Page 1
,TABLE OF CONTENTS
Section Content Area
1 Fundamentals, Safety, Infection Control & Health Assessment
2 Adult Medical-Surgical Nursing
3 Pharmacology & Medication Administration
4 Maternity & Newborn Nursing
5 Pediatric Nursing
6 Psychiatric & Mental Health Nursing
7 Critical Care, Emergency & Advanced Clinical Concepts
8 Leadership, Management, Delegation & Prioritization
9 Community Health, Gerontology, Ethics & Professional Practice
10 Integrated NGN Clinical-Judgment Case Studies
EXAM FEATURES
✓ 600 Original HESI-Style Practice Questions
✓ Difficult Clinical-Judgment & Priority Questions
✓ NGN-Inspired Unfolding Case Studies
✓ Detailed Rationales & Why-Not Explanations
✓ Clinical Pearls & Exam Strategies
✓ Medication Safety & Dosage Calculations
✓ Laboratory, Diagnostic & Fetal-Monitoring Interpretation
✓ Leadership, Delegation, Ethics & Professional Practice
✓ Word-Stable Tables, Flowcharts & Clinical Diagrams
✓ Comprehensive HESI RN Exit & NCLEX-RN Review
HESI RN Exit 2026–2027
Section 1 — Fundamentals, Safety, Infection Control & Health Assessment
Question 1
During evening safety rounds, the following findings are documented for four clients. Which finding requires the most immediate intervention?
A. A client with osteoarthritis requests assistance to the bathroom.
B. A postoperative client rates incisional pain 6/10.
C. A confused older adult is attempting to climb over raised side rails.
D. A client receiving IV fluids reports difficulty sleeping.
Correct Answer: C
Rationale: Climbing over raised side rails creates an immediate fall and injury risk. Raised rails can also function as a restraint when they prevent voluntary bed exit. The
priority is to remain with the client, reduce the unsafe barrier, assess causes of agitation, and institute individualized fall precautions.
Why the other options are less appropriate:
A requires assistance but presents no immediate crisis. B requires pain management but is not currently life-threatening. D is important for comfort but has lower priority
than preventing injury.
💡 Clinical Pearl: Four raised side rails can be considered a restraint when they restrict voluntary movement.
🎯 Exam Strategy: When HESI asks what requires immediate action, identify the situation in which harm could occur within seconds or minutes.
Question 2
A sterile urinary catheterization tray has been opened. Which observation means the nurse should discard the setup and obtain new sterile supplies?
A. The nurse reaches across the sterile field to pick up sterile forceps.
B. Sterile solution spills onto the inside of the sterile basin.
C. A sterile glove touches another sterile glove.
D. The sterile drape extends several centimeters over the bedside table.
Correct Answer: A
Rationale: Reaching across a sterile field places the nurse's clothing and potentially contaminated arm over sterile supplies, contaminating the field. Sterile objects must
remain in sight and above waist level, and personnel should avoid crossing directly over the sterile area.
Why the other options are less appropriate: B is expected when filling a sterile basin. C represents sterile-to-sterile contact. D is acceptable provided the field itself
remains dry and undisturbed.
💡 Clinical Pearl: The outer 2.5 cm (1 inch) of a sterile field is considered contaminated.
🎯 Exam Strategy: Look for anything that violates sterile-to-sterile, dry, visible, above-waist principles.
Question 3
A disoriented client repeatedly pulls at an IV catheter. Before requesting a restraint prescription, which intervention is most appropriate?
A. Place the IV tubing under clothing and provide frequent observation.
B. Apply bilateral wrist restraints loosely.
C. Raise all four side rails.
D. Administer a PRN sedative.
Correct Answer: A
Rationale: The least restrictive intervention must be attempted before physical restraints when clinically appropriate. Concealing tubing, reorientation, family presence,
diversion, closer observation, and relocating the client near the nursing station may reduce device manipulation without restricting movement.
Why the other options are less appropriate: B and C are restrictive interventions. D represents chemical restraint if used primarily to control behavior rather than treat a
clinical condition.
💡 Clinical Pearl: Restraints are a last resort—not a substitute for observation or environmental modification.
🎯 Exam Strategy: For restraint questions, choose the least restrictive effective intervention first unless immediate violence makes delay unsafe.
Question 4
Ten minutes after packed red blood cells are started, the client develops chills, lumbar pain, anxiety, and dyspnea. Which action should occur first?
A. Notify the blood bank.
B. Obtain a urine specimen.
C. Administer prescribed diphenhydramine.
D. Stop the blood transfusion.
Correct Answer: D
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,Rationale: An acute hemolytic transfusion reaction must be treated by immediately stopping the transfusion to prevent further incompatible blood from entering the
circulation. The nurse then maintains IV access with new tubing and normal saline and follows institutional reaction protocols.
Why the other options are less appropriate: A and B occur after transfusion cessation. C is inappropriate as the first intervention and may not treat a hemolytic reaction.
💡 Clinical Pearl: Stop blood first; keep the vein open with normal saline using new tubing.
🎯 Exam Strategy: When the source of deterioration is an infusion, oxygen delivery problem, or medication, ask whether stopping the source prevents
additional harm.
Question 5
A client admitted with profuse diarrhea has a positive stool assay for Clostridioides difficile. Which room setup is most appropriate?
A. Private room with contact precautions and dedicated equipment.
B. Negative-pressure room with an N95 respirator outside the door.
C. Positive-pressure room with sterile gowns for all visitors.
D. Standard precautions unless stool is visibly bloody.
Correct Answer: A
Rationale: C. difficile requires contact precautions in addition to standard precautions. A private room is preferred, and equipment such as blood-pressure cuffs and
thermometers should be dedicated whenever possible because spores can persist on environmental surfaces.
Why the other options are less appropriate: B describes airborne isolation. C is used for protective environments in selected immunocompromised clients. D fails to
prevent spore transmission.
💡 Clinical Pearl: For C. difficile, environmental cleaning requires a sporicidal agent according to facility protocol.
🎯 Exam Strategy: Associate diarrhea + spores = Contact + soap and water.
Question 6
Smoke begins coming from a wastebasket inside a client room. The client is awake but connected to oxygen. Which action should the nurse take first?
A. Activate the fire alarm.
B. Remove the client from immediate danger.
C. Attempt to extinguish the fire.
D. Close every door on the unit.
Correct Answer: B
Rationale: RACE begins with Rescue/Remove persons in immediate danger. The nurse should move the client away from the fire, then activate the alarm, contain the fire
by closing doors, and extinguish or evacuate as indicated.
Why the other options are less appropriate: A is second in RACE. C occurs only after rescue, alarm, and containment when safe. D is part of containment but not the
first action.
💡 Clinical Pearl: RACE = Rescue, Alarm, Contain, Extinguish/Evacuate.
🎯 Exam Strategy: Memorized sequences matter when the question gives no unusual factor requiring deviation.
Question 7
Before entering the room of a client with suspected pulmonary tuberculosis, which equipment is essential?
A. Surgical mask.
B. Fit-tested N95 respirator or equivalent.
C. Sterile gloves.
D. Face shield only.
Correct Answer: B
Rationale: Pulmonary tuberculosis is transmitted through airborne droplet nuclei. Healthcare personnel require a fit-tested respirator such as an N95, and the client should
be placed in an airborne infection isolation room with negative pressure when available.
Why the other options are less appropriate: A does not provide appropriate respiratory protection for airborne TB. C is unnecessary unless a sterile procedure is
performed. D does not filter inhaled airborne particles.
💡 Clinical Pearl: TB, measles, varicella → airborne precautions.
🎯 Exam Strategy: Differentiate protection for the nurse from source control for the client. The client may wear a surgical mask during transport; staff need
respiratory protection.
Question 8
Medication reconciliation reveals that a newly admitted client takes warfarin at home, but the medication is absent from the admission prescriptions. What should the nurse
do?
A. Administer the client's home supply.
B. Add warfarin to the medication administration record.
C. Wait until the next shift to verify the list.
D. Clarify the discrepancy with the prescribing clinician.
Correct Answer: D
Rationale: Medication reconciliation is intended to identify omissions, duplications, interactions, and dosing errors during transitions of care. The nurse cannot
independently prescribe or add warfarin but should promptly clarify the discrepancy with the responsible prescriber.
Why the other options are less appropriate: A and B exceed nursing authority without a valid prescription. C delays resolution of a potentially significant medication
omission.
💡 Clinical Pearl: Reconciliation is particularly important with anticoagulants, insulin, anticonvulsants, steroids, and cardiac medications.
🎯 Exam Strategy: When a prescription is missing, unclear, unsafe, or contradictory, clarify—do not guess.
Question 9 — Data Interpretation
A client reports dizziness when standing.
Position BP HR
Supine 132/76 72
Sitting 118/70 84
Standing 104/64 102
Which interpretation is most appropriate?
A. Normal physiologic response.
B. Isolated systolic hypertension.
C. Findings support orthostatic hypotension.
D. Findings indicate increased intracranial pressure.
Correct Answer: C
Rationale: The marked blood-pressure decline accompanied by compensatory tachycardia and positional symptoms strongly supports orthostatic hypotension. The client is
at increased fall risk and should be assisted with position changes while causes such as volume depletion or medications are evaluated.
Why the other options are less appropriate: A understates significant changes. B is not present. D is usually associated with a different hemodynamic and neurologic
pattern.
💡 Clinical Pearl: Orthostatic changes are clinically important when accompanied by dizziness, weakness, or syncope.
🎯 Exam Strategy: In table questions, do not evaluate one number alone—identify the trend plus symptoms.
Question 10 — Wound Assessment
The sacral wound below is documented:
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,How should the nurse classify the injury?
A. Stage 1 pressure injury.
B. Stage 3 pressure injury.
C. Stage 2 pressure injury.
D. Unstageable pressure injury.
Correct Answer: C
Rationale: Stage 2 pressure injury involves partial-thickness skin loss with exposed dermis and a viable pink/red wound bed without adipose, granulation tissue, slough, or
eschar. It may also present as a serum-filled blister.
Why the other options are less appropriate: A has intact skin. B involves full-thickness skin loss with visible adipose/granulation. D occurs when depth is obscured by
slough or eschar.
💡 Clinical Pearl: Do not use pressure-injury staging for moisture-associated skin damage or skin tears.
🎯 Exam Strategy: Determine whether skin is intact, partial-thickness, full-thickness, or obscured.
Question 11
A hospitalized infant has respiratory syncytial virus infection. Which action is most important when planning routine care?
A. Wear an N95 respirator for all contact.
B. Use contact precautions and meticulous hand hygiene.
C. Place the infant in a positive-pressure room.
D. Require sterile gloves before touching the infant.
Correct Answer: B
Rationale: RSV commonly spreads through respiratory secretions and contaminated hands or surfaces, making contact precautions essential. Depending on facility policy,
droplet measures may also be implemented. Hand hygiene and appropriate PPE interrupt transmission.
Why the other options are less appropriate: A is primarily required for airborne pathogens. C is inappropriate. D is unnecessary for routine contact.
💡 Clinical Pearl: Pediatric respiratory infections spread efficiently through toys, equipment, hands, and secretions.
🎯 Exam Strategy: HESI often tests the mode of transmission, not simply memorized disease names.
Question 12
A client begins having a generalized tonic-clonic seizure while sitting in a chair. What is the priority nursing action?
A. Insert an oral airway.
B. Lower the client safely to the floor and protect the head.
C. Restrain the client's extremities.
D. Give water when the jerking stops.
Correct Answer: B
Rationale: The immediate goal is injury prevention. The client should be safely lowered, nearby objects removed, the head protected, and the client positioned on the side
when possible after convulsive activity decreases to support airway drainage.
Why the other options are less appropriate: A can injure the mouth and teeth. C may cause musculoskeletal injury. D creates aspiration risk during the postictal period.
💡 Clinical Pearl: Never force anything into the mouth during a seizure.
🎯 Exam Strategy: During active seizures: protect—not restrain.
Question 13
The RN is assigning care to experienced unlicensed assistive personnel (UAP). Which task is appropriate to delegate?
A. Obtain routine vital signs for a stable postoperative client.
B. Determine whether a client's new confusion represents delirium.
C. Teach incentive spirometer use.
D. Evaluate a client's response to IV morphine.
Correct Answer: A
Rationale: Routine data collection for stable clients is within the typical UAP role. Assessment, interpretation, teaching, clinical judgment, and evaluation remain RN
responsibilities.
Why the other options are less appropriate: B requires assessment. C involves teaching. D requires evaluation after a medication intervention.
💡 Clinical Pearl: UAP can collect data; the RN interprets the data.
🎯 Exam Strategy: Avoid delegating tasks involving A-T-E: Assessment, Teaching, Evaluation.
Question 14
A client scheduled for surgery states, “I signed the form, but I still don't understand what could happen if I refuse the operation.” What should the nurse do?
A. Explain all surgical alternatives in detail.
B. Ask a family member to reinforce the surgeon's explanation.
C. Notify the surgeon that additional informed-consent discussion is needed.
D. Witness the signature and administer the preoperative sedative.
Correct Answer: C
Rationale: The provider performing the procedure is responsible for explaining the procedure, major risks, benefits, alternatives, and consequences of refusal. The nurse
may witness the signature and verify voluntariness but should stop the process when the client indicates inadequate understanding.
Why the other options are less appropriate: A exceeds the nurse's role regarding detailed procedural consent. B does not replace provider disclosure. D risks invalid
consent after sedation.
💡 Clinical Pearl: A signature alone does not prove informed consent.
🎯 Exam Strategy: If the client says “I don't understand,” think stop and clarify before proceeding.
Question 15
After assisting a client with C. difficile diarrhea and removing gloves, which hand-hygiene method is preferred?
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,A. Alcohol-based hand rub for 10 seconds.
B. Chlorhexidine wipe only.
C. Put on a second pair of clean gloves.
D. Wash hands thoroughly with soap and water.
Correct Answer: D
Rationale: Soap-and-water handwashing is preferred after caring for clients with C. difficile because mechanical friction helps remove spores from the hands. Alcohol-
based hand rubs have limited sporicidal activity.
Why the other options are less appropriate: A does not reliably remove spores. B is not a substitute for appropriate handwashing. C does not clean contaminated
hands.
💡 Clinical Pearl: C. diff = soap and water is a classic safety association.
🎯 Exam Strategy: Watch for exceptions to alcohol-based hand-rub use.
Question 16
Breakfast has arrived for a conscious client with diabetes. The bedside glucose reading is 54 mg/dL. The client is shaky but able to swallow safely. What should the nurse
do first?
A. Administer IM glucagon.
B. Give approximately 15 g of rapid-acting carbohydrate.
C. Administer scheduled rapid-acting insulin.
D. Encourage a high-protein meal without carbohydrate.
Correct Answer: B
Rationale: Conscious clients with symptomatic hypoglycemia who can swallow should receive approximately 15 g of rapidly absorbed carbohydrate followed by glucose
reassessment, often after about 15 minutes. More aggressive rescue therapy is reserved for clients unable to safely swallow.
Why the other options are less appropriate: A is generally used when oral treatment is unsafe or unavailable. C worsens hypoglycemia. D corrects glucose too slowly.
💡 Clinical Pearl: 15–15 approach: rapid carbohydrate, reassess, repeat if necessary.
🎯 Exam Strategy: Match the treatment route to the client's level of consciousness and swallowing ability.
Question 17
A client with dysphagia after a stroke is beginning lunch. Which intervention best reduces aspiration risk?
A. Position the client upright at approximately 90 degrees.
B. Offer thin liquids through a straw first.
C. Place food on the weak side of the mouth.
D. Encourage rapid eating before the food becomes cold.
Correct Answer: A
Rationale: Upright positioning improves swallowing mechanics and reduces aspiration risk. The client should remain upright after eating according to individualized
recommendations and should follow the prescribed consistency and speech-language pathology plan.
Why the other options are less appropriate: B may worsen aspiration in some dysphagia patterns. C generally places food where oral control is reduced. D increases
choking risk.
💡 Clinical Pearl: With unilateral oral weakness, food is generally directed toward the stronger side.
🎯 Exam Strategy: For aspiration-prevention questions, prioritize position, texture, pacing, and swallowing assessment.
Question 18
While drawing blood, the nurse sustains a needlestick from a hollow-bore needle used on a client. Which action is appropriate first?
A. Squeeze the puncture vigorously until it bleeds.
B. Complete an incident report before cleansing the site.
C. Call the client's family for permission to test blood.
D. Wash the area promptly with soap and water.
Correct Answer: D
Rationale: Immediate cleansing is the first action after a needlestick exposure. The nurse should then promptly report the exposure and follow occupational-health
procedures for source evaluation, baseline testing, and post-exposure prophylaxis when indicated.
Why the other options are less appropriate: A vigorous squeezing is not recommended. B delays immediate first aid. C is not the nurse's first responsibility and consent
procedures vary.
💡 Clinical Pearl: Occupational exposures are time-sensitive because some prophylaxis is most effective when started promptly.
🎯 Exam Strategy: Following exposure: clean → report → evaluate → prophylaxis/follow-up.
Question 19
Which observation in the room of a client receiving oxygen at 4 L/min by nasal cannula requires immediate correction?
A. A humidification bottle is available.
B. The client is wearing cotton clothing.
C. “Oxygen in Use” signage is posted.
D. Petroleum jelly is being applied around the client's nostrils.
Correct Answer: D
Rationale: Petroleum-based products can support combustion in oxygen-enriched environments and should be avoided. Water-soluble products should be used when
nasal lubrication is necessary.
Why the other options are less appropriate: A may be appropriate depending on therapy and institutional practice. B does not create the same ignition concern. C is an
appropriate safety precaution.
💡 Clinical Pearl: Oxygen itself does not burn, but it accelerates combustion.
🎯 Exam Strategy: Oxygen questions often test removal of heat, flame, spark, and petroleum sources.
Question 20
Two clients on the same unit have identical last names. Before administering medications, which method correctly identifies the intended client?
A. Ask the client to state full name and date of birth and compare them with the MAR/identification band.
B. Ask, “Are you Mr. Kamau?” and verify the room number.
C. Confirm the surname with another nurse.
D. Use the diagnosis and bed assignment as identifiers.
Correct Answer: A
Rationale: Medication administration requires at least two approved client identifiers, such as full name and date of birth or medical record number. Room and bed numbers
are not acceptable identifiers.
Why the other options are less appropriate: B uses a leading question and room number. C confirms only one identifier. D uses nonapproved identifiers.
💡 Clinical Pearl: Never use room number as a client identifier.
🎯 Exam Strategy: Choose the option where the client actively states identifying information whenever possible.
Question 21
While performing a sterile central-line dressing change, which event requires the nurse to change gloves before continuing?
A. The sterile glove touches sterile gauze.
B. The sterile glove touches the client's bed linen.
C. The sterile glove touches the sterile transparent dressing.
D. The sterile glove touches another sterile glove.
Correct Answer: B
Rationale: Bed linen is not sterile. Once a sterile glove contacts a nonsterile surface, it is contaminated and must be replaced before touching the catheter site or sterile
supplies.
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,Why the other options are less appropriate: A, C, and D are examples of sterile-to-sterile contact when properly performed.
💡 Clinical Pearl: One contaminated glove can compromise an entire central-line procedure.
🎯 Exam Strategy: Trace exactly what touched what in sterile-technique questions.
Question 22 — Disaster Triage
Four victims arrive after an explosion:
Victim Findings
1 Walking, superficial arm lacerations
2 Apneic until airway repositioning; then respirations 24/min
3 Closed ankle fracture, strong radial pulse
4 Extensive unsurvivable cranial destruction
Which victim should receive the immediate/red triage designation?
A. Victim 1
B. Victim 4
C. Victim 2
D. Victim 3
Correct Answer: C
Rationale: In mass-casualty triage, a person who begins breathing after airway repositioning requires immediate intervention and is classified as red. The objective is
maximizing survival with limited resources.
Why the other options are less appropriate: Victim 1 is likely minor/green. Victim 3 is likely delayed/yellow. Victim 4 would generally receive expectant/black designation
under disaster conditions.
💡 Clinical Pearl: Disaster priority differs from everyday emergency-room priority.
🎯 Exam Strategy: Think greatest good for the greatest number, not “sickest person first.”
Question 23
During admission, a client says, “Sometimes I think everyone would be better off if I weren't here.” What is the nurse's best response?
A. “You shouldn't say things like that.”
B. “Are you thinking about killing yourself, and have you made a plan?”
C. “Your family needs you, so focus on them.”
D. “We'll discuss that after your physical examination.”
Correct Answer: B
Rationale: Direct assessment of suicidal thoughts, intent, plan, means, and timing is appropriate and does not cause suicide. Safety assessment takes priority over
reassurance or avoidance.
Why the other options are less appropriate: A is judgmental. C minimizes the disclosure and may create guilt. D delays evaluation of a potentially life-threatening risk.
💡 Clinical Pearl: Asking directly about suicide is therapeutic and necessary.
🎯 Exam Strategy: When a client hints at self-harm, choose the response that clarifies risk directly.
Question 24
A client scheduled for surgery reports severe banana, avocado, and kiwi allergies. What should the nurse do?
A. Document the food allergies only because they are unrelated to surgery.
B. Alert the perioperative team to possible latex sensitivity.
C. Request prophylactic antibiotics immediately.
D. Remove iodine-containing supplies from the room.
Correct Answer: B
Rationale: Certain fruit allergies, including banana, avocado, kiwi, and chestnut, are associated with latex-fruit cross-reactivity. The perioperative team should be alerted so
a latex-safe environment can be arranged when clinically appropriate.
Why the other options are less appropriate: A misses an important safety association. C does not prevent latex reactions. D incorrectly links fruit allergy with iodine.
💡 Clinical Pearl: Banana–avocado–kiwi–chestnut should trigger consideration of latex sensitivity.
🎯 Exam Strategy: HESI often tests hidden safety connections embedded in the history.
Question 25
Which statement by a newly hired nurse indicates correct understanding of respiratory protection?
A. “A surgical mask can replace an N95 if the client has tuberculosis.”
B. “I can use any size N95 as long as it covers my nose and mouth.”
C. “I need appropriate fit testing for the respirator model I use.”
D. “Fit testing is required only after I develop respiratory symptoms.”
Correct Answer: C
Rationale: Tight-fitting respirators require appropriate fit testing to establish that the model and size form an adequate seal. A user seal check is also performed when the
respirator is donned.
Why the other options are less appropriate: A does not provide appropriate airborne protection. B ignores seal requirements. D misunderstands the purpose and timing
of fit testing.
💡 Clinical Pearl: Fit test ≠ user seal check; both have roles.
🎯 Exam Strategy: For occupational-safety questions, distinguish equipment availability from equipment properly fitted and used.
Question 26
After insertion of a nasogastric tube for enteral feeding, which method provides the most reliable confirmation of initial tube placement before feeding?
A. Inject air and auscultate over the stomach.
B. Obtain radiographic confirmation according to policy.
C. Observe the color of aspirated fluid only.
D. Place the end of the tube in water and watch for bubbles.
Correct Answer: B
Rationale: Radiographic verification is the standard reference method for confirming initial placement of a newly inserted feeding tube before nutrition or medications are
administered. Bedside techniques alone cannot reliably exclude respiratory placement.
Why the other options are less appropriate: A is unreliable. C cannot definitively establish anatomical location. D is unsafe and not an accepted method.
💡 Clinical Pearl: Never rely on the old “air bolus/whoosh” method to confirm feeding-tube placement.
🎯 Exam Strategy: When several bedside methods appear plausible, choose the one with the highest verification reliability.
Question 27
A client with cold fingers and dark nail polish has an oxygen saturation reading of 82%, but is speaking comfortably without dyspnea. What should the nurse do first?
A. Intubate the client.
B. Apply a nonrebreather mask at 15 L/min immediately.
C. Document chronic hypoxemia.
D. Assess the client and verify the reading using an appropriate alternate site or corrected sensor placement.
Correct Answer: D
Rationale: Pulse oximetry may be inaccurate with poor peripheral perfusion, motion, certain nail products, or sensor problems. Because the reading does not match the
clinical presentation, the nurse should assess the client and verify measurement accuracy while remaining alert for true hypoxemia.
Why the other options are less appropriate: A and B may be unnecessary without confirming the situation. C accepts an unverified abnormal result.
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,💡 Clinical Pearl: Treat the client—not a monitor in isolation.
🎯 Exam Strategy: When objective data conflict with clinical presentation, validate the data unless the client is unstable.
Question 28
A postoperative client says, “My pain is terrible,” while smiling and talking on the phone. Which nursing action is best?
A. Delay analgesia because behavior is inconsistent with severe pain.
B. Ask the client to rate and describe the pain using an appropriate scale.
C. Ask the family whether the client normally exaggerates symptoms.
D. Record the pain as mild based on observed behavior.
Correct Answer: B
Rationale: Pain is a subjective experience, and self-report is the preferred assessment when the client can communicate reliably. Behavior can provide additional
information but should not override the client's report.
Why the other options are less appropriate: A and D substitute observer judgment for client report. C is disrespectful and does not establish pain severity.
💡 Clinical Pearl: Pain is what the client says it is, within the context of comprehensive assessment.
🎯 Exam Strategy: Do not assume smiling, sleeping, or normal vital signs mean pain is absent.
Question 29
Which change-of-shift report requires the oncoming nurse to assess the client first?
A. “Client with pneumonia is awaiting discharge prescriptions.”
B. “Client with diabetes ate 75% of dinner.”
C. “Client with heart failure has new pink, frothy sputum and increasing restlessness.”
D. “Client with arthritis wants a heating pad.”
Correct Answer: D
Wait—Option C contains the emergency finding, but the predetermined answer sequence for Question 29 is D. To maintain clinical accuracy, Question 29 is corrected
below.
Question 29 — Corrected
Which change-of-shift report requires the oncoming nurse to assess the client first?
A. Client with pneumonia is awaiting discharge prescriptions.
B. Client with diabetes ate 75% of dinner.
C. Client with arthritis requests assistance repositioning.
D. Client with heart failure has new pink, frothy sputum and increasing restlessness.
Correct Answer: D
Rationale: Pink frothy sputum and restlessness suggest acute pulmonary edema and severe impaired oxygenation. Immediate respiratory assessment and intervention
take priority.
Why the other options are less appropriate: A is an administrative/discharge need. B is routine information. C requires comfort care but does not indicate impending
respiratory compromise.
💡 Clinical Pearl: Pink frothy sputum = pulmonary edema until proven otherwise.
🎯 Exam Strategy: New respiratory deterioration usually outranks routine medication, comfort, and discharge needs.
Question 30
Six hours after abdominal surgery, which assessment finding should the nurse address first?
A. Incisional pain rated 7/10.
B. Absent bowel sounds.
C. Respiratory rate 8/min after IV opioid administration.
D. Urine output of 40 mL during the previous hour.
Correct Answer: C
Rationale: A respiratory rate of 8/min after an opioid suggests potentially dangerous respiratory depression. Airway and breathing take priority over expected postoperative
findings and pain.
Why the other options are less appropriate: A requires management after stabilization. B may be expected temporarily after abdominal surgery. D is an acceptable
hourly output for many adults.
💡 Clinical Pearl: Sedation often precedes severe opioid-induced respiratory depression.
🎯 Exam Strategy: Postoperative questions frequently hide an ABC emergency among expected findings.
Question 31
During the beginning-of-shift emergency-cart check, which finding requires immediate correction?
A. The defibrillator is plugged into emergency power.
B. Oxygen equipment is present.
C. Emergency medications are within expiration dates.
D. The tamper seal is broken without documentation that the cart was checked and restocked.
Correct Answer: D
Rationale: A broken seal creates uncertainty about whether critical equipment and medications remain complete and functional. The cart must be inspected and restored to
readiness before an emergency occurs.
Why the other options are less appropriate: A, B, and C represent appropriate emergency preparedness.
💡 Clinical Pearl: Emergency equipment must be available, complete, functional, and immediately accessible.
🎯 Exam Strategy: Safety questions often ask which condition compromises readiness before the emergency even starts.
Question 32
After administering a subcutaneous injection using a safety-engineered needle, which action is correct?
A. Recap the needle using both hands.
B. Activate the safety device and immediately discard the needle in a sharps container.
C. Break the needle before disposal.
D. Place the used needle on the medication tray until charting is complete.
Correct Answer: C
This answer would be unsafe; the intended answer must be B based on clinical standards. Since the balanced sequence also assigns C to Question 32, I will replace the
question rather than compromise accuracy.
Question 32 — Corrected
Which item should be discarded in a regulated sharps container?
A. Blood-stained gauze without a sharp object.
B. Empty oral medication cup.
C. Used safety-engineered injection needle after activation of its safety feature.
D. Disposable gown used for contact precautions.
Correct Answer: C
Rationale: Used needles must be discarded immediately in approved puncture-resistant sharps containers. Safety features reduce but do not eliminate injury risk.
Why the other options are less appropriate: A may require biohazard disposal depending on saturation and policy but not a sharps container. B and D are not sharps.
💡 Clinical Pearl: Never bend, break, manipulate, or unnecessarily recap a used needle.
🎯 Exam Strategy: Disposal questions test what hazard the item creates—sharp, infectious waste, chemical, or ordinary waste.
Question 33
During a health history, the client uses a traditional herbal treatment. Which response by the nurse best demonstrates culturally responsive assessment?
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,A. “Traditional treatments interfere with evidence-based medicine.”
B. “You should stop all herbal remedies while hospitalized.”
C. “Tell me what you take, how you use it, and what you believe it helps with.”
D. “Only prescription drugs need to be included in your medication history.”
Correct Answer: C
Rationale: Open-ended, nonjudgmental inquiry supports culturally responsive care while allowing the nurse to identify possible medication interactions or safety issues.
Cultural practices should be assessed rather than automatically dismissed.
Why the other options are less appropriate: A and B may damage trust and ignore individual practices. D creates an incomplete medication history.
💡 Clinical Pearl: Ask about herbs, supplements, teas, traditional remedies, and nonprescription medications.
🎯 Exam Strategy: Choose responses that invite explanation without stereotyping.
Question 34
An 82-year-old hospitalized client who was oriented yesterday becomes restless overnight, attempts to pull out the IV, and cannot maintain attention. Which interpretation is
most likely?
A. Normal aging.
B. Chronic dementia.
C. Acute delirium requiring assessment for an underlying cause.
D. Expected adjustment to hospitalization.
Correct Answer: C
Rationale: Abrupt onset, fluctuating cognition, altered attention, and behavioral change are characteristic of delirium. Potential causes such as infection, hypoxia,
medications, metabolic abnormalities, pain, or urinary retention should be investigated promptly.
Why the other options are less appropriate: A is not normal aging. B usually develops progressively rather than overnight. D underestimates an acute change.
💡 Clinical Pearl: Delirium = acute and fluctuating; dementia = usually chronic and progressive.
🎯 Exam Strategy: A sudden mental-status change is a clinical symptom, not simply “confusion in old age.”
Question 35 — Neurologic Assessment
Which finding is most concerning during a neurologic reassessment after a head injury?
A. Client recalls three objects after 5 minutes.
B. Pupils are equal and react briskly to light.
C. Glasgow Coma Scale decreases from 15 to 12.
D. Client complains of mild scalp tenderness.
Correct Answer: C
Rationale: A decline in Glasgow Coma Scale score represents worsening neurologic status and may indicate increasing intracranial pathology. Trending neurologic findings
is more meaningful than a single isolated score.
Why the other options are less appropriate: A and B are reassuring findings. D may occur with local injury but does not signal the same neurologic deterioration.
💡 Clinical Pearl: Trend matters. A falling GCS is more concerning than a stable low-risk isolated symptom.
🎯 Exam Strategy: HESI frequently rewards recognition of change from baseline.
Question 36 — Pressure Injury Risk
A client has the following Braden Scale findings:
Domain Finding
Mobility Very limited
Moisture Frequently moist
Nutrition Probably inadequate
Sensory perception Slightly limited
Friction/shear Problem
Which intervention is most appropriate?
A. Massage reddened bony prominences every shift.
B. Place a donut-shaped device beneath the sacrum.
C. Restrict fluid intake to keep the skin dry.
D. Implement an individualized pressure-injury prevention plan with repositioning, moisture management, nutrition support, and pressure redistribution.
Correct Answer: D
Rationale: Multiple risk factors require a comprehensive prevention strategy addressing mobility, pressure redistribution, moisture, nutrition, and friction/shear. Prevention
should be individualized according to the client's overall risk.
Why the other options are less appropriate: A may damage compromised tissue. B can concentrate pressure. C may worsen dehydration and skin integrity.
💡 Clinical Pearl: Pressure injury prevention is multifactorial; turning alone is rarely enough.
🎯 Exam Strategy: When several risk factors are present, favor the comprehensive intervention over a single isolated measure.
Question 37
Which sequence begins the generally recommended process for donning PPE before entering a room requiring gown, mask, eye protection, and gloves?
A. Gloves → gown → mask → eye protection
B. Gown → mask/respirator → eye protection → gloves
C. Mask → gloves → gown → eye protection
D. Eye protection → gloves → gown → mask
Correct Answer: B
Rationale: A commonly taught donning sequence is gown, mask or respirator, eye protection, then gloves. Gloves generally go on last so they cover the cuffs of the gown.
Why the other options are less appropriate: The alternative sequences increase the likelihood of poor coverage or contamination during donning.
💡 Clinical Pearl: Don PPE from cleaner foundational layers outward; gloves usually last.
🎯 Exam Strategy: Do not confuse donning order with removal order.
Question 38
A client's neighbor calls the unit and asks, “Is she there? I heard she was admitted after an accident.” Which response is appropriate when the client has not authorized
disclosure?
A. “I cannot confirm or discuss whether that person is receiving care here.”
B. “Yes, but I cannot tell you what happened.”
C. “She is stable, but you'll need to call her family.”
D. “I can confirm admission because you already know about the accident.”
Correct Answer: A
Rationale: The nurse should protect the client's privacy and follow facility directory/privacy preferences. Unauthorized callers should not receive protected information
merely because they know the client's name or circumstances.
Why the other options are less appropriate: B, C, and D disclose information without established authorization.
💡 Clinical Pearl: Even confirming hospitalization may constitute disclosure in certain circumstances.
🎯 Exam Strategy: When authorization is unclear, choose the option that protects confidentiality.
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,Question 39
A competent client has an advance directive refusing mechanical ventilation under specified circumstances. The family demands “everything possible.” What should guide
nursing care?
A. The family's preference because they are next of kin.
B. The oldest child's decision.
C. The attending nurse's personal beliefs.
D. The competent client's expressed wishes and valid advance-care decisions.
Correct Answer: D
Rationale: Competent adults have the right to make healthcare decisions, including refusal of treatment. A valid advance directive communicates those preferences when
the defined circumstances apply and should guide care in accordance with law and institutional policy.
Why the other options are less appropriate: Family members do not automatically override the client's autonomous choices. The nurse's beliefs should not supersede
the client's decisions.
💡 Clinical Pearl: Autonomy follows the client, not the loudest family member.
🎯 Exam Strategy: In ethics questions, identify whose rights and decisions legally govern the situation.
Question 40
A client slips while walking to the bathroom but reports no pain and has no obvious injury. Which documentation is appropriate?
A. Chart, “Incident report completed because client fell.”
B. Do not chart the fall unless an injury develops.
C. Document objective assessment findings, circumstances, interventions, and notifications in the medical record without referencing the incident report.
D. Record that the UAP was responsible for the fall.
Correct Answer: C
Rationale: The medical record should contain objective clinical facts, assessment results, interventions, and appropriate notifications. The incident report is part of the
facility's risk-management process and should generally not be referenced in the medical record.
Why the other options are less appropriate: A incorrectly references the incident report. B omits a significant event. D assigns blame rather than documenting facts.
💡 Clinical Pearl: Chart the event and client response—not the incident report.
🎯 Exam Strategy: Legal documentation should be factual, timely, objective, and free of blame.
Question 41
The nurse discovers that a medication error was caught before the drug reached the client. Which action is appropriate?
A. Follow facility near-miss reporting procedures and evaluate how the error almost occurred.
B. Ignore the event because no medication was administered.
C. Document in the client's chart that another nurse nearly caused harm.
D. Destroy the medication and tell no one.
Correct Answer: A
Rationale: Near misses provide important information about system vulnerabilities and should be reported according to institutional safety processes. Learning from near
misses can prevent future adverse events.
Why the other options are less appropriate: B and D conceal safety information. C uses the clinical record to assign blame and may be inappropriate when the client
never received the medication.
💡 Clinical Pearl: High-reliability organizations learn from near misses, not only injuries.
🎯 Exam Strategy: Patient-safety questions favor system improvement over blame.
Question 42
A restrained client is being monitored. Which finding requires immediate intervention?
A. Client asks what time restraints can be discontinued.
B. Respirations are 18/min.
C. Fingers distal to a wrist restraint are pale, cool, and have delayed capillary refill.
D. Restraint ties are secured to the bed frame using a quick-release knot.
Correct Answer: C
Rationale: Pale, cool extremities with delayed capillary refill suggest impaired circulation from excessive restraint pressure or positioning. The nurse should intervene
immediately and reassess neurovascular status.
Why the other options are less appropriate: A requires communication but is not a physiologic emergency. B is normal. D is generally an appropriate securing
technique.
💡 Clinical Pearl: Restraint monitoring includes circulation, skin, respiratory status, nutrition/hydration, elimination, comfort, and continued necessity.
🎯 Exam Strategy: Look for neurovascular compromise whenever devices surround an extremity.
Question 43
The electronic record lists “penicillin allergy,” but no reaction is documented. Before administering a newly prescribed antibiotic, what should the nurse do?
A. Ask the client what reaction occurred and when.
B. Delete the allergy because documentation is incomplete.
C. Administer the drug and observe for a reaction.
D. Assume all beta-lactam antibiotics are absolutely contraindicated.
Correct Answer: A
Rationale: Clarifying the nature, severity, and timing of a reported allergy distinguishes true hypersensitivity from intolerance or unrelated symptoms and supports safe
antibiotic selection. The allergy should not simply be removed or ignored.
Why the other options are less appropriate: B alters safety information without evidence. C exposes the client to avoidable risk. D overgeneralizes without assessment.
💡 Clinical Pearl: “Allergy” documentation should ideally include the specific reaction.
🎯 Exam Strategy: When information is incomplete but obtainable, assess before assuming.
Question 44 — Home Safety
Which home modification is most important for an older adult with impaired balance and nocturia?
A. Add loose throw rugs to provide cushioning.
B. Encourage walking in socks to improve foot sensation.
C. Keep frequently used objects on high shelves to promote stretching.
D. Install adequate nighttime lighting and clear the path between the bed and bathroom.
Correct Answer: D
Rationale: Nocturnal bathroom trips combined with impaired balance substantially increase fall risk. Clear walking paths, adequate lighting, stable footwear, grab bars when
indicated, and removal of loose rugs are key interventions.
Why the other options are less appropriate: A increases tripping risk. B reduces traction. C creates reaching and balance hazards.
💡 Clinical Pearl: Falls are often produced by multiple small hazards acting together.
🎯 Exam Strategy: Select environmental changes that remove hazards rather than expecting the client to compensate for them.
HESI RN Exit 2026–2027 • Premium Word-Stable Edition | Page 9
, Question 45 — Chain of Infection
Which nursing intervention most directly interrupts the mode of transmission for many healthcare-associated infections?
A. Administering antipyretics.
B. Increasing dietary protein.
C. Closing the client's door.
D. Performing correct hand hygiene at appropriate moments.
Correct Answer: D
Rationale: Hand hygiene directly interrupts transfer of microorganisms between clients, staff, equipment, and environmental surfaces. It is among the most important
interventions for preventing healthcare-associated infection.
Why the other options are less appropriate: A treats symptoms. B may improve host resilience but does not directly interrupt transmission. C is indicated only for certain
precautions and is not universally protective.
💡 Clinical Pearl: Hand hygiene targets the transmission link in the chain of infection.
🎯 Exam Strategy: Match the intervention to the exact link the question names.
Question 46
Twenty-four hours after surgery, the nurse notes a small amount of thin, pink drainage on the dressing. How should this drainage be documented?
A. Purulent.
B. Serosanguineous.
C. Sanguineous.
D. Serous.
Correct Answer: B
Rationale: Serosanguineous drainage is thin and watery with a pink or pale-red appearance caused by a mixture of serum and small amounts of blood. A limited amount
can occur during early wound healing.
Why the other options are less appropriate: A is thick and often yellow/green/tan. C is primarily bloody. D is clear or pale-yellow serum.
💡 Clinical Pearl: Drainage terminology: serous = clear; sanguineous = blood; serosanguineous = pink; purulent = pus-like.
🎯 Exam Strategy: Use the physical description rather than assuming that all postoperative drainage is abnormal.
Question 47
During neurologic assessment, which finding should the nurse report promptly?
A. Pupils 3 mm, equal and briskly reactive.
B. New unilateral pupil dilation with decreased responsiveness.
C. Symmetric hand grasps.
D. Oriented responses to person, place, and time.
Correct Answer: B
Rationale: New anisocoria combined with deteriorating responsiveness may indicate acute neurologic compression or rising intracranial pressure and warrants urgent
evaluation.
Why the other options are less appropriate: A, C, and D are reassuring neurologic findings.
💡 Clinical Pearl: A new pupil asymmetry is much more important than a long-standing benign difference.
🎯 Exam Strategy: Combine abnormal cues. Pupil change plus consciousness change is more concerning than either alone.
Question 48
A client becomes light-headed when standing from bed for the first time after surgery. Which nursing response is best?
A. Return the client to a safe sitting or supine position and reassess vital signs/symptoms.
B. Encourage the client to continue walking to improve circulation.
C. Leave briefly to obtain a walker.
D. Ask the client to close the eyes and stand still.
Correct Answer: A
Rationale: Light-headedness during mobilization may signal orthostatic hypotension or instability. Preventing a fall is immediate priority; the client should be supported to a
safe position and reassessed before further ambulation.
Why the other options are less appropriate: B increases fall risk. C leaves an unstable client unattended. D does not correct the physiologic or safety problem.
💡 Clinical Pearl: First ambulation after surgery should be gradual and supervised.
🎯 Exam Strategy: When dizziness appears during mobility, prevent the fall before investigating the cause.
Question 49 — Abdominal Assessment
Which sequence is correct for a routine abdominal examination?
A. Inspection → palpation → percussion → auscultation
B. Palpation → inspection → auscultation → percussion
C. Auscultation → percussion → palpation → inspection
D. Inspection → auscultation → percussion → palpation
Correct Answer: D
Rationale: The abdomen is assessed using inspection, auscultation, percussion, then palpation. Auscultation occurs before percussion and palpation because
manipulating the abdomen may alter bowel sounds.
Why the other options are less appropriate: They auscultate after abdominal manipulation or begin with palpation, potentially changing the findings.
💡 Clinical Pearl: The abdomen is the classic exception to the usual inspect-palpate-percuss-auscultate pattern.
🎯 Exam Strategy: Remember I-A-P-P for abdominal assessment.
Question 50 — Peripheral Vascular Assessment
A client's lower legs are assessed:
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HESI RN Exit 2026–2027 • Premium Word-Stable Edition | Page 1
,TABLE OF CONTENTS
Section Content Area
1 Fundamentals, Safety, Infection Control & Health Assessment
2 Adult Medical-Surgical Nursing
3 Pharmacology & Medication Administration
4 Maternity & Newborn Nursing
5 Pediatric Nursing
6 Psychiatric & Mental Health Nursing
7 Critical Care, Emergency & Advanced Clinical Concepts
8 Leadership, Management, Delegation & Prioritization
9 Community Health, Gerontology, Ethics & Professional Practice
10 Integrated NGN Clinical-Judgment Case Studies
EXAM FEATURES
✓ 600 Original HESI-Style Practice Questions
✓ Difficult Clinical-Judgment & Priority Questions
✓ NGN-Inspired Unfolding Case Studies
✓ Detailed Rationales & Why-Not Explanations
✓ Clinical Pearls & Exam Strategies
✓ Medication Safety & Dosage Calculations
✓ Laboratory, Diagnostic & Fetal-Monitoring Interpretation
✓ Leadership, Delegation, Ethics & Professional Practice
✓ Word-Stable Tables, Flowcharts & Clinical Diagrams
✓ Comprehensive HESI RN Exit & NCLEX-RN Review
HESI RN Exit 2026–2027
Section 1 — Fundamentals, Safety, Infection Control & Health Assessment
Question 1
During evening safety rounds, the following findings are documented for four clients. Which finding requires the most immediate intervention?
A. A client with osteoarthritis requests assistance to the bathroom.
B. A postoperative client rates incisional pain 6/10.
C. A confused older adult is attempting to climb over raised side rails.
D. A client receiving IV fluids reports difficulty sleeping.
Correct Answer: C
Rationale: Climbing over raised side rails creates an immediate fall and injury risk. Raised rails can also function as a restraint when they prevent voluntary bed exit. The
priority is to remain with the client, reduce the unsafe barrier, assess causes of agitation, and institute individualized fall precautions.
Why the other options are less appropriate:
A requires assistance but presents no immediate crisis. B requires pain management but is not currently life-threatening. D is important for comfort but has lower priority
than preventing injury.
💡 Clinical Pearl: Four raised side rails can be considered a restraint when they restrict voluntary movement.
🎯 Exam Strategy: When HESI asks what requires immediate action, identify the situation in which harm could occur within seconds or minutes.
Question 2
A sterile urinary catheterization tray has been opened. Which observation means the nurse should discard the setup and obtain new sterile supplies?
A. The nurse reaches across the sterile field to pick up sterile forceps.
B. Sterile solution spills onto the inside of the sterile basin.
C. A sterile glove touches another sterile glove.
D. The sterile drape extends several centimeters over the bedside table.
Correct Answer: A
Rationale: Reaching across a sterile field places the nurse's clothing and potentially contaminated arm over sterile supplies, contaminating the field. Sterile objects must
remain in sight and above waist level, and personnel should avoid crossing directly over the sterile area.
Why the other options are less appropriate: B is expected when filling a sterile basin. C represents sterile-to-sterile contact. D is acceptable provided the field itself
remains dry and undisturbed.
💡 Clinical Pearl: The outer 2.5 cm (1 inch) of a sterile field is considered contaminated.
🎯 Exam Strategy: Look for anything that violates sterile-to-sterile, dry, visible, above-waist principles.
Question 3
A disoriented client repeatedly pulls at an IV catheter. Before requesting a restraint prescription, which intervention is most appropriate?
A. Place the IV tubing under clothing and provide frequent observation.
B. Apply bilateral wrist restraints loosely.
C. Raise all four side rails.
D. Administer a PRN sedative.
Correct Answer: A
Rationale: The least restrictive intervention must be attempted before physical restraints when clinically appropriate. Concealing tubing, reorientation, family presence,
diversion, closer observation, and relocating the client near the nursing station may reduce device manipulation without restricting movement.
Why the other options are less appropriate: B and C are restrictive interventions. D represents chemical restraint if used primarily to control behavior rather than treat a
clinical condition.
💡 Clinical Pearl: Restraints are a last resort—not a substitute for observation or environmental modification.
🎯 Exam Strategy: For restraint questions, choose the least restrictive effective intervention first unless immediate violence makes delay unsafe.
Question 4
Ten minutes after packed red blood cells are started, the client develops chills, lumbar pain, anxiety, and dyspnea. Which action should occur first?
A. Notify the blood bank.
B. Obtain a urine specimen.
C. Administer prescribed diphenhydramine.
D. Stop the blood transfusion.
Correct Answer: D
HESI RN Exit 2026–2027 • Premium Word-Stable Edition | Page 2
,Rationale: An acute hemolytic transfusion reaction must be treated by immediately stopping the transfusion to prevent further incompatible blood from entering the
circulation. The nurse then maintains IV access with new tubing and normal saline and follows institutional reaction protocols.
Why the other options are less appropriate: A and B occur after transfusion cessation. C is inappropriate as the first intervention and may not treat a hemolytic reaction.
💡 Clinical Pearl: Stop blood first; keep the vein open with normal saline using new tubing.
🎯 Exam Strategy: When the source of deterioration is an infusion, oxygen delivery problem, or medication, ask whether stopping the source prevents
additional harm.
Question 5
A client admitted with profuse diarrhea has a positive stool assay for Clostridioides difficile. Which room setup is most appropriate?
A. Private room with contact precautions and dedicated equipment.
B. Negative-pressure room with an N95 respirator outside the door.
C. Positive-pressure room with sterile gowns for all visitors.
D. Standard precautions unless stool is visibly bloody.
Correct Answer: A
Rationale: C. difficile requires contact precautions in addition to standard precautions. A private room is preferred, and equipment such as blood-pressure cuffs and
thermometers should be dedicated whenever possible because spores can persist on environmental surfaces.
Why the other options are less appropriate: B describes airborne isolation. C is used for protective environments in selected immunocompromised clients. D fails to
prevent spore transmission.
💡 Clinical Pearl: For C. difficile, environmental cleaning requires a sporicidal agent according to facility protocol.
🎯 Exam Strategy: Associate diarrhea + spores = Contact + soap and water.
Question 6
Smoke begins coming from a wastebasket inside a client room. The client is awake but connected to oxygen. Which action should the nurse take first?
A. Activate the fire alarm.
B. Remove the client from immediate danger.
C. Attempt to extinguish the fire.
D. Close every door on the unit.
Correct Answer: B
Rationale: RACE begins with Rescue/Remove persons in immediate danger. The nurse should move the client away from the fire, then activate the alarm, contain the fire
by closing doors, and extinguish or evacuate as indicated.
Why the other options are less appropriate: A is second in RACE. C occurs only after rescue, alarm, and containment when safe. D is part of containment but not the
first action.
💡 Clinical Pearl: RACE = Rescue, Alarm, Contain, Extinguish/Evacuate.
🎯 Exam Strategy: Memorized sequences matter when the question gives no unusual factor requiring deviation.
Question 7
Before entering the room of a client with suspected pulmonary tuberculosis, which equipment is essential?
A. Surgical mask.
B. Fit-tested N95 respirator or equivalent.
C. Sterile gloves.
D. Face shield only.
Correct Answer: B
Rationale: Pulmonary tuberculosis is transmitted through airborne droplet nuclei. Healthcare personnel require a fit-tested respirator such as an N95, and the client should
be placed in an airborne infection isolation room with negative pressure when available.
Why the other options are less appropriate: A does not provide appropriate respiratory protection for airborne TB. C is unnecessary unless a sterile procedure is
performed. D does not filter inhaled airborne particles.
💡 Clinical Pearl: TB, measles, varicella → airborne precautions.
🎯 Exam Strategy: Differentiate protection for the nurse from source control for the client. The client may wear a surgical mask during transport; staff need
respiratory protection.
Question 8
Medication reconciliation reveals that a newly admitted client takes warfarin at home, but the medication is absent from the admission prescriptions. What should the nurse
do?
A. Administer the client's home supply.
B. Add warfarin to the medication administration record.
C. Wait until the next shift to verify the list.
D. Clarify the discrepancy with the prescribing clinician.
Correct Answer: D
Rationale: Medication reconciliation is intended to identify omissions, duplications, interactions, and dosing errors during transitions of care. The nurse cannot
independently prescribe or add warfarin but should promptly clarify the discrepancy with the responsible prescriber.
Why the other options are less appropriate: A and B exceed nursing authority without a valid prescription. C delays resolution of a potentially significant medication
omission.
💡 Clinical Pearl: Reconciliation is particularly important with anticoagulants, insulin, anticonvulsants, steroids, and cardiac medications.
🎯 Exam Strategy: When a prescription is missing, unclear, unsafe, or contradictory, clarify—do not guess.
Question 9 — Data Interpretation
A client reports dizziness when standing.
Position BP HR
Supine 132/76 72
Sitting 118/70 84
Standing 104/64 102
Which interpretation is most appropriate?
A. Normal physiologic response.
B. Isolated systolic hypertension.
C. Findings support orthostatic hypotension.
D. Findings indicate increased intracranial pressure.
Correct Answer: C
Rationale: The marked blood-pressure decline accompanied by compensatory tachycardia and positional symptoms strongly supports orthostatic hypotension. The client is
at increased fall risk and should be assisted with position changes while causes such as volume depletion or medications are evaluated.
Why the other options are less appropriate: A understates significant changes. B is not present. D is usually associated with a different hemodynamic and neurologic
pattern.
💡 Clinical Pearl: Orthostatic changes are clinically important when accompanied by dizziness, weakness, or syncope.
🎯 Exam Strategy: In table questions, do not evaluate one number alone—identify the trend plus symptoms.
Question 10 — Wound Assessment
The sacral wound below is documented:
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,How should the nurse classify the injury?
A. Stage 1 pressure injury.
B. Stage 3 pressure injury.
C. Stage 2 pressure injury.
D. Unstageable pressure injury.
Correct Answer: C
Rationale: Stage 2 pressure injury involves partial-thickness skin loss with exposed dermis and a viable pink/red wound bed without adipose, granulation tissue, slough, or
eschar. It may also present as a serum-filled blister.
Why the other options are less appropriate: A has intact skin. B involves full-thickness skin loss with visible adipose/granulation. D occurs when depth is obscured by
slough or eschar.
💡 Clinical Pearl: Do not use pressure-injury staging for moisture-associated skin damage or skin tears.
🎯 Exam Strategy: Determine whether skin is intact, partial-thickness, full-thickness, or obscured.
Question 11
A hospitalized infant has respiratory syncytial virus infection. Which action is most important when planning routine care?
A. Wear an N95 respirator for all contact.
B. Use contact precautions and meticulous hand hygiene.
C. Place the infant in a positive-pressure room.
D. Require sterile gloves before touching the infant.
Correct Answer: B
Rationale: RSV commonly spreads through respiratory secretions and contaminated hands or surfaces, making contact precautions essential. Depending on facility policy,
droplet measures may also be implemented. Hand hygiene and appropriate PPE interrupt transmission.
Why the other options are less appropriate: A is primarily required for airborne pathogens. C is inappropriate. D is unnecessary for routine contact.
💡 Clinical Pearl: Pediatric respiratory infections spread efficiently through toys, equipment, hands, and secretions.
🎯 Exam Strategy: HESI often tests the mode of transmission, not simply memorized disease names.
Question 12
A client begins having a generalized tonic-clonic seizure while sitting in a chair. What is the priority nursing action?
A. Insert an oral airway.
B. Lower the client safely to the floor and protect the head.
C. Restrain the client's extremities.
D. Give water when the jerking stops.
Correct Answer: B
Rationale: The immediate goal is injury prevention. The client should be safely lowered, nearby objects removed, the head protected, and the client positioned on the side
when possible after convulsive activity decreases to support airway drainage.
Why the other options are less appropriate: A can injure the mouth and teeth. C may cause musculoskeletal injury. D creates aspiration risk during the postictal period.
💡 Clinical Pearl: Never force anything into the mouth during a seizure.
🎯 Exam Strategy: During active seizures: protect—not restrain.
Question 13
The RN is assigning care to experienced unlicensed assistive personnel (UAP). Which task is appropriate to delegate?
A. Obtain routine vital signs for a stable postoperative client.
B. Determine whether a client's new confusion represents delirium.
C. Teach incentive spirometer use.
D. Evaluate a client's response to IV morphine.
Correct Answer: A
Rationale: Routine data collection for stable clients is within the typical UAP role. Assessment, interpretation, teaching, clinical judgment, and evaluation remain RN
responsibilities.
Why the other options are less appropriate: B requires assessment. C involves teaching. D requires evaluation after a medication intervention.
💡 Clinical Pearl: UAP can collect data; the RN interprets the data.
🎯 Exam Strategy: Avoid delegating tasks involving A-T-E: Assessment, Teaching, Evaluation.
Question 14
A client scheduled for surgery states, “I signed the form, but I still don't understand what could happen if I refuse the operation.” What should the nurse do?
A. Explain all surgical alternatives in detail.
B. Ask a family member to reinforce the surgeon's explanation.
C. Notify the surgeon that additional informed-consent discussion is needed.
D. Witness the signature and administer the preoperative sedative.
Correct Answer: C
Rationale: The provider performing the procedure is responsible for explaining the procedure, major risks, benefits, alternatives, and consequences of refusal. The nurse
may witness the signature and verify voluntariness but should stop the process when the client indicates inadequate understanding.
Why the other options are less appropriate: A exceeds the nurse's role regarding detailed procedural consent. B does not replace provider disclosure. D risks invalid
consent after sedation.
💡 Clinical Pearl: A signature alone does not prove informed consent.
🎯 Exam Strategy: If the client says “I don't understand,” think stop and clarify before proceeding.
Question 15
After assisting a client with C. difficile diarrhea and removing gloves, which hand-hygiene method is preferred?
HESI RN Exit 2026–2027 • Premium Word-Stable Edition | Page 4
,A. Alcohol-based hand rub for 10 seconds.
B. Chlorhexidine wipe only.
C. Put on a second pair of clean gloves.
D. Wash hands thoroughly with soap and water.
Correct Answer: D
Rationale: Soap-and-water handwashing is preferred after caring for clients with C. difficile because mechanical friction helps remove spores from the hands. Alcohol-
based hand rubs have limited sporicidal activity.
Why the other options are less appropriate: A does not reliably remove spores. B is not a substitute for appropriate handwashing. C does not clean contaminated
hands.
💡 Clinical Pearl: C. diff = soap and water is a classic safety association.
🎯 Exam Strategy: Watch for exceptions to alcohol-based hand-rub use.
Question 16
Breakfast has arrived for a conscious client with diabetes. The bedside glucose reading is 54 mg/dL. The client is shaky but able to swallow safely. What should the nurse
do first?
A. Administer IM glucagon.
B. Give approximately 15 g of rapid-acting carbohydrate.
C. Administer scheduled rapid-acting insulin.
D. Encourage a high-protein meal without carbohydrate.
Correct Answer: B
Rationale: Conscious clients with symptomatic hypoglycemia who can swallow should receive approximately 15 g of rapidly absorbed carbohydrate followed by glucose
reassessment, often after about 15 minutes. More aggressive rescue therapy is reserved for clients unable to safely swallow.
Why the other options are less appropriate: A is generally used when oral treatment is unsafe or unavailable. C worsens hypoglycemia. D corrects glucose too slowly.
💡 Clinical Pearl: 15–15 approach: rapid carbohydrate, reassess, repeat if necessary.
🎯 Exam Strategy: Match the treatment route to the client's level of consciousness and swallowing ability.
Question 17
A client with dysphagia after a stroke is beginning lunch. Which intervention best reduces aspiration risk?
A. Position the client upright at approximately 90 degrees.
B. Offer thin liquids through a straw first.
C. Place food on the weak side of the mouth.
D. Encourage rapid eating before the food becomes cold.
Correct Answer: A
Rationale: Upright positioning improves swallowing mechanics and reduces aspiration risk. The client should remain upright after eating according to individualized
recommendations and should follow the prescribed consistency and speech-language pathology plan.
Why the other options are less appropriate: B may worsen aspiration in some dysphagia patterns. C generally places food where oral control is reduced. D increases
choking risk.
💡 Clinical Pearl: With unilateral oral weakness, food is generally directed toward the stronger side.
🎯 Exam Strategy: For aspiration-prevention questions, prioritize position, texture, pacing, and swallowing assessment.
Question 18
While drawing blood, the nurse sustains a needlestick from a hollow-bore needle used on a client. Which action is appropriate first?
A. Squeeze the puncture vigorously until it bleeds.
B. Complete an incident report before cleansing the site.
C. Call the client's family for permission to test blood.
D. Wash the area promptly with soap and water.
Correct Answer: D
Rationale: Immediate cleansing is the first action after a needlestick exposure. The nurse should then promptly report the exposure and follow occupational-health
procedures for source evaluation, baseline testing, and post-exposure prophylaxis when indicated.
Why the other options are less appropriate: A vigorous squeezing is not recommended. B delays immediate first aid. C is not the nurse's first responsibility and consent
procedures vary.
💡 Clinical Pearl: Occupational exposures are time-sensitive because some prophylaxis is most effective when started promptly.
🎯 Exam Strategy: Following exposure: clean → report → evaluate → prophylaxis/follow-up.
Question 19
Which observation in the room of a client receiving oxygen at 4 L/min by nasal cannula requires immediate correction?
A. A humidification bottle is available.
B. The client is wearing cotton clothing.
C. “Oxygen in Use” signage is posted.
D. Petroleum jelly is being applied around the client's nostrils.
Correct Answer: D
Rationale: Petroleum-based products can support combustion in oxygen-enriched environments and should be avoided. Water-soluble products should be used when
nasal lubrication is necessary.
Why the other options are less appropriate: A may be appropriate depending on therapy and institutional practice. B does not create the same ignition concern. C is an
appropriate safety precaution.
💡 Clinical Pearl: Oxygen itself does not burn, but it accelerates combustion.
🎯 Exam Strategy: Oxygen questions often test removal of heat, flame, spark, and petroleum sources.
Question 20
Two clients on the same unit have identical last names. Before administering medications, which method correctly identifies the intended client?
A. Ask the client to state full name and date of birth and compare them with the MAR/identification band.
B. Ask, “Are you Mr. Kamau?” and verify the room number.
C. Confirm the surname with another nurse.
D. Use the diagnosis and bed assignment as identifiers.
Correct Answer: A
Rationale: Medication administration requires at least two approved client identifiers, such as full name and date of birth or medical record number. Room and bed numbers
are not acceptable identifiers.
Why the other options are less appropriate: B uses a leading question and room number. C confirms only one identifier. D uses nonapproved identifiers.
💡 Clinical Pearl: Never use room number as a client identifier.
🎯 Exam Strategy: Choose the option where the client actively states identifying information whenever possible.
Question 21
While performing a sterile central-line dressing change, which event requires the nurse to change gloves before continuing?
A. The sterile glove touches sterile gauze.
B. The sterile glove touches the client's bed linen.
C. The sterile glove touches the sterile transparent dressing.
D. The sterile glove touches another sterile glove.
Correct Answer: B
Rationale: Bed linen is not sterile. Once a sterile glove contacts a nonsterile surface, it is contaminated and must be replaced before touching the catheter site or sterile
supplies.
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,Why the other options are less appropriate: A, C, and D are examples of sterile-to-sterile contact when properly performed.
💡 Clinical Pearl: One contaminated glove can compromise an entire central-line procedure.
🎯 Exam Strategy: Trace exactly what touched what in sterile-technique questions.
Question 22 — Disaster Triage
Four victims arrive after an explosion:
Victim Findings
1 Walking, superficial arm lacerations
2 Apneic until airway repositioning; then respirations 24/min
3 Closed ankle fracture, strong radial pulse
4 Extensive unsurvivable cranial destruction
Which victim should receive the immediate/red triage designation?
A. Victim 1
B. Victim 4
C. Victim 2
D. Victim 3
Correct Answer: C
Rationale: In mass-casualty triage, a person who begins breathing after airway repositioning requires immediate intervention and is classified as red. The objective is
maximizing survival with limited resources.
Why the other options are less appropriate: Victim 1 is likely minor/green. Victim 3 is likely delayed/yellow. Victim 4 would generally receive expectant/black designation
under disaster conditions.
💡 Clinical Pearl: Disaster priority differs from everyday emergency-room priority.
🎯 Exam Strategy: Think greatest good for the greatest number, not “sickest person first.”
Question 23
During admission, a client says, “Sometimes I think everyone would be better off if I weren't here.” What is the nurse's best response?
A. “You shouldn't say things like that.”
B. “Are you thinking about killing yourself, and have you made a plan?”
C. “Your family needs you, so focus on them.”
D. “We'll discuss that after your physical examination.”
Correct Answer: B
Rationale: Direct assessment of suicidal thoughts, intent, plan, means, and timing is appropriate and does not cause suicide. Safety assessment takes priority over
reassurance or avoidance.
Why the other options are less appropriate: A is judgmental. C minimizes the disclosure and may create guilt. D delays evaluation of a potentially life-threatening risk.
💡 Clinical Pearl: Asking directly about suicide is therapeutic and necessary.
🎯 Exam Strategy: When a client hints at self-harm, choose the response that clarifies risk directly.
Question 24
A client scheduled for surgery reports severe banana, avocado, and kiwi allergies. What should the nurse do?
A. Document the food allergies only because they are unrelated to surgery.
B. Alert the perioperative team to possible latex sensitivity.
C. Request prophylactic antibiotics immediately.
D. Remove iodine-containing supplies from the room.
Correct Answer: B
Rationale: Certain fruit allergies, including banana, avocado, kiwi, and chestnut, are associated with latex-fruit cross-reactivity. The perioperative team should be alerted so
a latex-safe environment can be arranged when clinically appropriate.
Why the other options are less appropriate: A misses an important safety association. C does not prevent latex reactions. D incorrectly links fruit allergy with iodine.
💡 Clinical Pearl: Banana–avocado–kiwi–chestnut should trigger consideration of latex sensitivity.
🎯 Exam Strategy: HESI often tests hidden safety connections embedded in the history.
Question 25
Which statement by a newly hired nurse indicates correct understanding of respiratory protection?
A. “A surgical mask can replace an N95 if the client has tuberculosis.”
B. “I can use any size N95 as long as it covers my nose and mouth.”
C. “I need appropriate fit testing for the respirator model I use.”
D. “Fit testing is required only after I develop respiratory symptoms.”
Correct Answer: C
Rationale: Tight-fitting respirators require appropriate fit testing to establish that the model and size form an adequate seal. A user seal check is also performed when the
respirator is donned.
Why the other options are less appropriate: A does not provide appropriate airborne protection. B ignores seal requirements. D misunderstands the purpose and timing
of fit testing.
💡 Clinical Pearl: Fit test ≠ user seal check; both have roles.
🎯 Exam Strategy: For occupational-safety questions, distinguish equipment availability from equipment properly fitted and used.
Question 26
After insertion of a nasogastric tube for enteral feeding, which method provides the most reliable confirmation of initial tube placement before feeding?
A. Inject air and auscultate over the stomach.
B. Obtain radiographic confirmation according to policy.
C. Observe the color of aspirated fluid only.
D. Place the end of the tube in water and watch for bubbles.
Correct Answer: B
Rationale: Radiographic verification is the standard reference method for confirming initial placement of a newly inserted feeding tube before nutrition or medications are
administered. Bedside techniques alone cannot reliably exclude respiratory placement.
Why the other options are less appropriate: A is unreliable. C cannot definitively establish anatomical location. D is unsafe and not an accepted method.
💡 Clinical Pearl: Never rely on the old “air bolus/whoosh” method to confirm feeding-tube placement.
🎯 Exam Strategy: When several bedside methods appear plausible, choose the one with the highest verification reliability.
Question 27
A client with cold fingers and dark nail polish has an oxygen saturation reading of 82%, but is speaking comfortably without dyspnea. What should the nurse do first?
A. Intubate the client.
B. Apply a nonrebreather mask at 15 L/min immediately.
C. Document chronic hypoxemia.
D. Assess the client and verify the reading using an appropriate alternate site or corrected sensor placement.
Correct Answer: D
Rationale: Pulse oximetry may be inaccurate with poor peripheral perfusion, motion, certain nail products, or sensor problems. Because the reading does not match the
clinical presentation, the nurse should assess the client and verify measurement accuracy while remaining alert for true hypoxemia.
Why the other options are less appropriate: A and B may be unnecessary without confirming the situation. C accepts an unverified abnormal result.
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,💡 Clinical Pearl: Treat the client—not a monitor in isolation.
🎯 Exam Strategy: When objective data conflict with clinical presentation, validate the data unless the client is unstable.
Question 28
A postoperative client says, “My pain is terrible,” while smiling and talking on the phone. Which nursing action is best?
A. Delay analgesia because behavior is inconsistent with severe pain.
B. Ask the client to rate and describe the pain using an appropriate scale.
C. Ask the family whether the client normally exaggerates symptoms.
D. Record the pain as mild based on observed behavior.
Correct Answer: B
Rationale: Pain is a subjective experience, and self-report is the preferred assessment when the client can communicate reliably. Behavior can provide additional
information but should not override the client's report.
Why the other options are less appropriate: A and D substitute observer judgment for client report. C is disrespectful and does not establish pain severity.
💡 Clinical Pearl: Pain is what the client says it is, within the context of comprehensive assessment.
🎯 Exam Strategy: Do not assume smiling, sleeping, or normal vital signs mean pain is absent.
Question 29
Which change-of-shift report requires the oncoming nurse to assess the client first?
A. “Client with pneumonia is awaiting discharge prescriptions.”
B. “Client with diabetes ate 75% of dinner.”
C. “Client with heart failure has new pink, frothy sputum and increasing restlessness.”
D. “Client with arthritis wants a heating pad.”
Correct Answer: D
Wait—Option C contains the emergency finding, but the predetermined answer sequence for Question 29 is D. To maintain clinical accuracy, Question 29 is corrected
below.
Question 29 — Corrected
Which change-of-shift report requires the oncoming nurse to assess the client first?
A. Client with pneumonia is awaiting discharge prescriptions.
B. Client with diabetes ate 75% of dinner.
C. Client with arthritis requests assistance repositioning.
D. Client with heart failure has new pink, frothy sputum and increasing restlessness.
Correct Answer: D
Rationale: Pink frothy sputum and restlessness suggest acute pulmonary edema and severe impaired oxygenation. Immediate respiratory assessment and intervention
take priority.
Why the other options are less appropriate: A is an administrative/discharge need. B is routine information. C requires comfort care but does not indicate impending
respiratory compromise.
💡 Clinical Pearl: Pink frothy sputum = pulmonary edema until proven otherwise.
🎯 Exam Strategy: New respiratory deterioration usually outranks routine medication, comfort, and discharge needs.
Question 30
Six hours after abdominal surgery, which assessment finding should the nurse address first?
A. Incisional pain rated 7/10.
B. Absent bowel sounds.
C. Respiratory rate 8/min after IV opioid administration.
D. Urine output of 40 mL during the previous hour.
Correct Answer: C
Rationale: A respiratory rate of 8/min after an opioid suggests potentially dangerous respiratory depression. Airway and breathing take priority over expected postoperative
findings and pain.
Why the other options are less appropriate: A requires management after stabilization. B may be expected temporarily after abdominal surgery. D is an acceptable
hourly output for many adults.
💡 Clinical Pearl: Sedation often precedes severe opioid-induced respiratory depression.
🎯 Exam Strategy: Postoperative questions frequently hide an ABC emergency among expected findings.
Question 31
During the beginning-of-shift emergency-cart check, which finding requires immediate correction?
A. The defibrillator is plugged into emergency power.
B. Oxygen equipment is present.
C. Emergency medications are within expiration dates.
D. The tamper seal is broken without documentation that the cart was checked and restocked.
Correct Answer: D
Rationale: A broken seal creates uncertainty about whether critical equipment and medications remain complete and functional. The cart must be inspected and restored to
readiness before an emergency occurs.
Why the other options are less appropriate: A, B, and C represent appropriate emergency preparedness.
💡 Clinical Pearl: Emergency equipment must be available, complete, functional, and immediately accessible.
🎯 Exam Strategy: Safety questions often ask which condition compromises readiness before the emergency even starts.
Question 32
After administering a subcutaneous injection using a safety-engineered needle, which action is correct?
A. Recap the needle using both hands.
B. Activate the safety device and immediately discard the needle in a sharps container.
C. Break the needle before disposal.
D. Place the used needle on the medication tray until charting is complete.
Correct Answer: C
This answer would be unsafe; the intended answer must be B based on clinical standards. Since the balanced sequence also assigns C to Question 32, I will replace the
question rather than compromise accuracy.
Question 32 — Corrected
Which item should be discarded in a regulated sharps container?
A. Blood-stained gauze without a sharp object.
B. Empty oral medication cup.
C. Used safety-engineered injection needle after activation of its safety feature.
D. Disposable gown used for contact precautions.
Correct Answer: C
Rationale: Used needles must be discarded immediately in approved puncture-resistant sharps containers. Safety features reduce but do not eliminate injury risk.
Why the other options are less appropriate: A may require biohazard disposal depending on saturation and policy but not a sharps container. B and D are not sharps.
💡 Clinical Pearl: Never bend, break, manipulate, or unnecessarily recap a used needle.
🎯 Exam Strategy: Disposal questions test what hazard the item creates—sharp, infectious waste, chemical, or ordinary waste.
Question 33
During a health history, the client uses a traditional herbal treatment. Which response by the nurse best demonstrates culturally responsive assessment?
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,A. “Traditional treatments interfere with evidence-based medicine.”
B. “You should stop all herbal remedies while hospitalized.”
C. “Tell me what you take, how you use it, and what you believe it helps with.”
D. “Only prescription drugs need to be included in your medication history.”
Correct Answer: C
Rationale: Open-ended, nonjudgmental inquiry supports culturally responsive care while allowing the nurse to identify possible medication interactions or safety issues.
Cultural practices should be assessed rather than automatically dismissed.
Why the other options are less appropriate: A and B may damage trust and ignore individual practices. D creates an incomplete medication history.
💡 Clinical Pearl: Ask about herbs, supplements, teas, traditional remedies, and nonprescription medications.
🎯 Exam Strategy: Choose responses that invite explanation without stereotyping.
Question 34
An 82-year-old hospitalized client who was oriented yesterday becomes restless overnight, attempts to pull out the IV, and cannot maintain attention. Which interpretation is
most likely?
A. Normal aging.
B. Chronic dementia.
C. Acute delirium requiring assessment for an underlying cause.
D. Expected adjustment to hospitalization.
Correct Answer: C
Rationale: Abrupt onset, fluctuating cognition, altered attention, and behavioral change are characteristic of delirium. Potential causes such as infection, hypoxia,
medications, metabolic abnormalities, pain, or urinary retention should be investigated promptly.
Why the other options are less appropriate: A is not normal aging. B usually develops progressively rather than overnight. D underestimates an acute change.
💡 Clinical Pearl: Delirium = acute and fluctuating; dementia = usually chronic and progressive.
🎯 Exam Strategy: A sudden mental-status change is a clinical symptom, not simply “confusion in old age.”
Question 35 — Neurologic Assessment
Which finding is most concerning during a neurologic reassessment after a head injury?
A. Client recalls three objects after 5 minutes.
B. Pupils are equal and react briskly to light.
C. Glasgow Coma Scale decreases from 15 to 12.
D. Client complains of mild scalp tenderness.
Correct Answer: C
Rationale: A decline in Glasgow Coma Scale score represents worsening neurologic status and may indicate increasing intracranial pathology. Trending neurologic findings
is more meaningful than a single isolated score.
Why the other options are less appropriate: A and B are reassuring findings. D may occur with local injury but does not signal the same neurologic deterioration.
💡 Clinical Pearl: Trend matters. A falling GCS is more concerning than a stable low-risk isolated symptom.
🎯 Exam Strategy: HESI frequently rewards recognition of change from baseline.
Question 36 — Pressure Injury Risk
A client has the following Braden Scale findings:
Domain Finding
Mobility Very limited
Moisture Frequently moist
Nutrition Probably inadequate
Sensory perception Slightly limited
Friction/shear Problem
Which intervention is most appropriate?
A. Massage reddened bony prominences every shift.
B. Place a donut-shaped device beneath the sacrum.
C. Restrict fluid intake to keep the skin dry.
D. Implement an individualized pressure-injury prevention plan with repositioning, moisture management, nutrition support, and pressure redistribution.
Correct Answer: D
Rationale: Multiple risk factors require a comprehensive prevention strategy addressing mobility, pressure redistribution, moisture, nutrition, and friction/shear. Prevention
should be individualized according to the client's overall risk.
Why the other options are less appropriate: A may damage compromised tissue. B can concentrate pressure. C may worsen dehydration and skin integrity.
💡 Clinical Pearl: Pressure injury prevention is multifactorial; turning alone is rarely enough.
🎯 Exam Strategy: When several risk factors are present, favor the comprehensive intervention over a single isolated measure.
Question 37
Which sequence begins the generally recommended process for donning PPE before entering a room requiring gown, mask, eye protection, and gloves?
A. Gloves → gown → mask → eye protection
B. Gown → mask/respirator → eye protection → gloves
C. Mask → gloves → gown → eye protection
D. Eye protection → gloves → gown → mask
Correct Answer: B
Rationale: A commonly taught donning sequence is gown, mask or respirator, eye protection, then gloves. Gloves generally go on last so they cover the cuffs of the gown.
Why the other options are less appropriate: The alternative sequences increase the likelihood of poor coverage or contamination during donning.
💡 Clinical Pearl: Don PPE from cleaner foundational layers outward; gloves usually last.
🎯 Exam Strategy: Do not confuse donning order with removal order.
Question 38
A client's neighbor calls the unit and asks, “Is she there? I heard she was admitted after an accident.” Which response is appropriate when the client has not authorized
disclosure?
A. “I cannot confirm or discuss whether that person is receiving care here.”
B. “Yes, but I cannot tell you what happened.”
C. “She is stable, but you'll need to call her family.”
D. “I can confirm admission because you already know about the accident.”
Correct Answer: A
Rationale: The nurse should protect the client's privacy and follow facility directory/privacy preferences. Unauthorized callers should not receive protected information
merely because they know the client's name or circumstances.
Why the other options are less appropriate: B, C, and D disclose information without established authorization.
💡 Clinical Pearl: Even confirming hospitalization may constitute disclosure in certain circumstances.
🎯 Exam Strategy: When authorization is unclear, choose the option that protects confidentiality.
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,Question 39
A competent client has an advance directive refusing mechanical ventilation under specified circumstances. The family demands “everything possible.” What should guide
nursing care?
A. The family's preference because they are next of kin.
B. The oldest child's decision.
C. The attending nurse's personal beliefs.
D. The competent client's expressed wishes and valid advance-care decisions.
Correct Answer: D
Rationale: Competent adults have the right to make healthcare decisions, including refusal of treatment. A valid advance directive communicates those preferences when
the defined circumstances apply and should guide care in accordance with law and institutional policy.
Why the other options are less appropriate: Family members do not automatically override the client's autonomous choices. The nurse's beliefs should not supersede
the client's decisions.
💡 Clinical Pearl: Autonomy follows the client, not the loudest family member.
🎯 Exam Strategy: In ethics questions, identify whose rights and decisions legally govern the situation.
Question 40
A client slips while walking to the bathroom but reports no pain and has no obvious injury. Which documentation is appropriate?
A. Chart, “Incident report completed because client fell.”
B. Do not chart the fall unless an injury develops.
C. Document objective assessment findings, circumstances, interventions, and notifications in the medical record without referencing the incident report.
D. Record that the UAP was responsible for the fall.
Correct Answer: C
Rationale: The medical record should contain objective clinical facts, assessment results, interventions, and appropriate notifications. The incident report is part of the
facility's risk-management process and should generally not be referenced in the medical record.
Why the other options are less appropriate: A incorrectly references the incident report. B omits a significant event. D assigns blame rather than documenting facts.
💡 Clinical Pearl: Chart the event and client response—not the incident report.
🎯 Exam Strategy: Legal documentation should be factual, timely, objective, and free of blame.
Question 41
The nurse discovers that a medication error was caught before the drug reached the client. Which action is appropriate?
A. Follow facility near-miss reporting procedures and evaluate how the error almost occurred.
B. Ignore the event because no medication was administered.
C. Document in the client's chart that another nurse nearly caused harm.
D. Destroy the medication and tell no one.
Correct Answer: A
Rationale: Near misses provide important information about system vulnerabilities and should be reported according to institutional safety processes. Learning from near
misses can prevent future adverse events.
Why the other options are less appropriate: B and D conceal safety information. C uses the clinical record to assign blame and may be inappropriate when the client
never received the medication.
💡 Clinical Pearl: High-reliability organizations learn from near misses, not only injuries.
🎯 Exam Strategy: Patient-safety questions favor system improvement over blame.
Question 42
A restrained client is being monitored. Which finding requires immediate intervention?
A. Client asks what time restraints can be discontinued.
B. Respirations are 18/min.
C. Fingers distal to a wrist restraint are pale, cool, and have delayed capillary refill.
D. Restraint ties are secured to the bed frame using a quick-release knot.
Correct Answer: C
Rationale: Pale, cool extremities with delayed capillary refill suggest impaired circulation from excessive restraint pressure or positioning. The nurse should intervene
immediately and reassess neurovascular status.
Why the other options are less appropriate: A requires communication but is not a physiologic emergency. B is normal. D is generally an appropriate securing
technique.
💡 Clinical Pearl: Restraint monitoring includes circulation, skin, respiratory status, nutrition/hydration, elimination, comfort, and continued necessity.
🎯 Exam Strategy: Look for neurovascular compromise whenever devices surround an extremity.
Question 43
The electronic record lists “penicillin allergy,” but no reaction is documented. Before administering a newly prescribed antibiotic, what should the nurse do?
A. Ask the client what reaction occurred and when.
B. Delete the allergy because documentation is incomplete.
C. Administer the drug and observe for a reaction.
D. Assume all beta-lactam antibiotics are absolutely contraindicated.
Correct Answer: A
Rationale: Clarifying the nature, severity, and timing of a reported allergy distinguishes true hypersensitivity from intolerance or unrelated symptoms and supports safe
antibiotic selection. The allergy should not simply be removed or ignored.
Why the other options are less appropriate: B alters safety information without evidence. C exposes the client to avoidable risk. D overgeneralizes without assessment.
💡 Clinical Pearl: “Allergy” documentation should ideally include the specific reaction.
🎯 Exam Strategy: When information is incomplete but obtainable, assess before assuming.
Question 44 — Home Safety
Which home modification is most important for an older adult with impaired balance and nocturia?
A. Add loose throw rugs to provide cushioning.
B. Encourage walking in socks to improve foot sensation.
C. Keep frequently used objects on high shelves to promote stretching.
D. Install adequate nighttime lighting and clear the path between the bed and bathroom.
Correct Answer: D
Rationale: Nocturnal bathroom trips combined with impaired balance substantially increase fall risk. Clear walking paths, adequate lighting, stable footwear, grab bars when
indicated, and removal of loose rugs are key interventions.
Why the other options are less appropriate: A increases tripping risk. B reduces traction. C creates reaching and balance hazards.
💡 Clinical Pearl: Falls are often produced by multiple small hazards acting together.
🎯 Exam Strategy: Select environmental changes that remove hazards rather than expecting the client to compensate for them.
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, Question 45 — Chain of Infection
Which nursing intervention most directly interrupts the mode of transmission for many healthcare-associated infections?
A. Administering antipyretics.
B. Increasing dietary protein.
C. Closing the client's door.
D. Performing correct hand hygiene at appropriate moments.
Correct Answer: D
Rationale: Hand hygiene directly interrupts transfer of microorganisms between clients, staff, equipment, and environmental surfaces. It is among the most important
interventions for preventing healthcare-associated infection.
Why the other options are less appropriate: A treats symptoms. B may improve host resilience but does not directly interrupt transmission. C is indicated only for certain
precautions and is not universally protective.
💡 Clinical Pearl: Hand hygiene targets the transmission link in the chain of infection.
🎯 Exam Strategy: Match the intervention to the exact link the question names.
Question 46
Twenty-four hours after surgery, the nurse notes a small amount of thin, pink drainage on the dressing. How should this drainage be documented?
A. Purulent.
B. Serosanguineous.
C. Sanguineous.
D. Serous.
Correct Answer: B
Rationale: Serosanguineous drainage is thin and watery with a pink or pale-red appearance caused by a mixture of serum and small amounts of blood. A limited amount
can occur during early wound healing.
Why the other options are less appropriate: A is thick and often yellow/green/tan. C is primarily bloody. D is clear or pale-yellow serum.
💡 Clinical Pearl: Drainage terminology: serous = clear; sanguineous = blood; serosanguineous = pink; purulent = pus-like.
🎯 Exam Strategy: Use the physical description rather than assuming that all postoperative drainage is abnormal.
Question 47
During neurologic assessment, which finding should the nurse report promptly?
A. Pupils 3 mm, equal and briskly reactive.
B. New unilateral pupil dilation with decreased responsiveness.
C. Symmetric hand grasps.
D. Oriented responses to person, place, and time.
Correct Answer: B
Rationale: New anisocoria combined with deteriorating responsiveness may indicate acute neurologic compression or rising intracranial pressure and warrants urgent
evaluation.
Why the other options are less appropriate: A, C, and D are reassuring neurologic findings.
💡 Clinical Pearl: A new pupil asymmetry is much more important than a long-standing benign difference.
🎯 Exam Strategy: Combine abnormal cues. Pupil change plus consciousness change is more concerning than either alone.
Question 48
A client becomes light-headed when standing from bed for the first time after surgery. Which nursing response is best?
A. Return the client to a safe sitting or supine position and reassess vital signs/symptoms.
B. Encourage the client to continue walking to improve circulation.
C. Leave briefly to obtain a walker.
D. Ask the client to close the eyes and stand still.
Correct Answer: A
Rationale: Light-headedness during mobilization may signal orthostatic hypotension or instability. Preventing a fall is immediate priority; the client should be supported to a
safe position and reassessed before further ambulation.
Why the other options are less appropriate: B increases fall risk. C leaves an unstable client unattended. D does not correct the physiologic or safety problem.
💡 Clinical Pearl: First ambulation after surgery should be gradual and supervised.
🎯 Exam Strategy: When dizziness appears during mobility, prevent the fall before investigating the cause.
Question 49 — Abdominal Assessment
Which sequence is correct for a routine abdominal examination?
A. Inspection → palpation → percussion → auscultation
B. Palpation → inspection → auscultation → percussion
C. Auscultation → percussion → palpation → inspection
D. Inspection → auscultation → percussion → palpation
Correct Answer: D
Rationale: The abdomen is assessed using inspection, auscultation, percussion, then palpation. Auscultation occurs before percussion and palpation because
manipulating the abdomen may alter bowel sounds.
Why the other options are less appropriate: They auscultate after abdominal manipulation or begin with palpation, potentially changing the findings.
💡 Clinical Pearl: The abdomen is the classic exception to the usual inspect-palpate-percuss-auscultate pattern.
🎯 Exam Strategy: Remember I-A-P-P for abdominal assessment.
Question 50 — Peripheral Vascular Assessment
A client's lower legs are assessed:
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