[HESI RN EXIT EXAM V2 ] – QUESTIONS AND ANSWERS | VERIFIED AND
WELL DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS |
LATEST EXAM UPDATE
Core Domains
Management of Care
Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Basic Care and Comfort
Pharmacological and Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
IntroductionThe HESI RN Exit Exam serves as a comprehensive evaluation
designed to measure a graduating nursing student's readiness to successfully
pass the NCLEX-RN and enter professional clinical practice. This rigorous
assessment evaluates integrated clinical knowledge, clinical judgment, and
safe, competent care across diverse healthcare settings. Utilizing a
sophisticated multiple-choice and scenario-based structure, the exam tests the
student's ability to prioritize nursing interventions, delegate appropriately,
manage complex patient acuities, and navigate ethical dilemmas. The emphasis
centers strictly on real-world application, critical thinking, and decisive clinical
decision-making to ensure optimal patient outcomes and professional
accountability.
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client admitted with diabetic ketoacidosis (DKA).
Which of the following initial prescriptions should the nurse anticipate
implementing first?
A. Administer regular insulin 10 units IV bolus
B. Initiate an intravenous infusion of 0.9% sodium chloride
C. Administer sodium bicarbonate 50 mEq IV
D. Obtain a glycosylated hemoglobin (HbA1c) level
🟢 B. Initiate an intravenous infusion of 0.9% sodium chloride
🔴 Explanation: Fluid resuscitation is the absolute first priority in
managing DKA to restore intravascular volume and tissue perfusion
,before administering insulin, which can precipitate a rapid drop in
potassium and fluid volume.
A nurse is assessing a client who is 2 hours post-thyroidectomy. Which of
the following findings requires immediate notification of the primary
healthcare provider?
A. Report of mild incisional pain at the surgical site
B. Soft, high-pitched voice when speaking to the nurse
C. Development of stridor and noticeable muscle twitching
D. Serosanguineous drainage on the dressing measuring 2 cm
🟢 C. Development of stridor and noticeable muscle twitching
🔴 Explanation: Stridor indicates acute laryngeal edema and airway
obstruction, a medical emergency. Muscle twitching suggests
hypocalcemia due to accidental parathyroid gland damage.
An adult client diagnosed with major depressive disorder is prescribed
fluoxetine. The nurse provides education about the medication. Which
client statement indicates a need for further teaching?
A. "I should expect to feel the full therapeutic effects of this medication
within 24 to 48 hours."
B. "I must avoid taking over-the-counter NSAIDs like ibuprofen without
consulting my doctor."
C. "I will report any thoughts of self-harm or worsening depression
immediately."
D. "I should avoid abruptly stopping this medication to prevent withdrawal
symptoms."
🟢 A. "I should expect to feel the full therapeutic effects of this medication
within 24 to 48 hours."
🔴 Explanation: Selective serotonin reuptake inhibitors (SSRIs) like
fluoxetine typically require 2 to 4 weeks, and sometimes up to 6 weeks, to
achieve full therapeutic efficacy.
A nurse is preparing to administer digoxin to a client with heart failure. The
apical pulse rate is measured at 52 beats per minute. What is the correct
nursing action?
A. Administer the prescribed dose and document the pulse rate
B. Withhold the dose and notify the primary healthcare provider
C. Recheck the pulse rate in 30 minutes and administer if greater than 60
D. Administer half of the prescribed dose and recheck vital signs
🟢 B. Withhold the dose and notify the primary healthcare provider
🔴 Explanation: Digoxin should be withheld if the adult client's apical
pulse is less than 60 beats per minute to prevent severe bradycardia and
digitalis toxicity.
,A nurse enters a client's room and finds the client unresponsive,
pulseless, and not breathing. After calling for emergency assistance and
retrieving the emergency cart, what is the next immediate nursing action?
A. Administer two rescue breaths using a bag-valve-mask device
B. Locate the carotid pulse for no more than 10 seconds
C. Begin high-quality chest compressions at a rate of 100 to 120 per
minute
D. Attach the automated external defibrillator pads
🟢 C. Begin high-quality chest compressions at a rate of 100 to 120 per
minute
🔴 Explanation: According to basic life support guidelines, establishing
immediate chest compressions minimizes delay in circulating oxygenated
blood to vital organs.
A community health nurse is planning an educational program for older
adults regarding osteoporosis prevention. Which of the following dietary
modifications should the nurse emphasize?
A. Increasing consumption of iron-rich organ meats
B. Consuming adequate amounts of calcium and vitamin D
C. Eliminating all dietary carbohydrates and sugars
D. Doubling daily protein intake through red meat consumption
🟢 B. Consuming adequate amounts of calcium and vitamin D
🔴 Explanation: Calcium and vitamin D are vital for maintaining bone
mineral density and preventing the progression of osteoporosis in older
adults.
A nurse is caring for a client with a newly placed chest tube connected to
a water-seal drainage system. The nurse notices continuous bubbling in
the water-seal chamber. What is the priority nursing action?
A. Document the finding as a normal expected outcome
B. Lower the drainage system below the level of the client's chest
C. Inspect the entire tubing system carefully for an air leak
D. Strip the chest tube vigorously to dislodge any clots
🟢 C. Inspect the entire tubing system carefully for an air leak
🔴 Explanation: Continuous bubbling in the water-seal chamber indicates
an air leak within the system or at the insertion site, which must be located
and resolved immediately.
A client is receiving a blood transfusion and develops lower back pain,
chills, and dark urine after 15 minutes of infusion. Which action should the
nurse take first?
A. Slow the rate of the blood transfusion by half
B. Stop the transfusion immediately and disconnect the tubing
C. Administer the prescribed diphenhydramine hydrochloride
D. Collect a blood sample for kidney function testing
, 🟢 B. Stop the transfusion immediately and disconnect the tubing
🔴 Explanation: These symptoms indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the line kept
open with normal saline using new tubing.
A nurse is planning care for a client diagnosed with obsessive-compulsive
disorder (OCD) who engages in frequent handwashing rituals. Which
nursing intervention is most appropriate during the initial phase of care?
A. Prevent the client from performing the ritual to promote behavioral
extinction
B. Allow time for the ritual while gradually setting limits on the behavior
C. Confront the client about the irrational nature of the handwashing
D. Restrict the client to the room to reduce environmental triggers
🟢 B. Allow time for the ritual while gradually setting limits on the behavior
🔴 Explanation: Abruptly stopping a ritual increases anxiety significantly.
Allowing time initially while setting structured limits helps reduce anxiety
safely while working toward behavior modification.
A nurse is reviewing lab results for a client receiving heparin therapy via
continuous intravenous infusion. Which laboratory value should the nurse
monitor to evaluate the effectiveness of this therapy?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
🟢 C. Activated partial thromboplastin time (aPTT)
🔴 Explanation: The aPTT is specifically used to monitor the therapeutic
efficacy of unfractionated heparin therapy, adjusting the infusion rate per
established protocols.
A nurse is assessing a client with suspected appendicitis. Which of the
following findings is characteristic of this condition?
A. Pain located in the left upper quadrant radiating to the shoulder
B. Rebound tenderness located at McBurney's point
C. Severe cramping pain relieved completely by defecation
D. Constant dull ache in the suprapubic region during urination
🟢 B. Rebound tenderness located at McBurney's point
🔴 Explanation: Appendicitis classically presents with right lower quadrant
abdominal pain, specifically localized at McBurney's point, accompanied
by rebound tenderness.
A nurse is caring for an older adult client who exhibits signs of acute
delirium. Which of the following interventions should be included in the
care plan?
A. Restrain all four extremities to prevent accidental falls
WELL DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS |
LATEST EXAM UPDATE
Core Domains
Management of Care
Safety and Infection Control
Health Promotion and Maintenance
Psychosocial Integrity
Basic Care and Comfort
Pharmacological and Parenteral Therapies
Reduction of Risk Potential
Physiological Adaptation
IntroductionThe HESI RN Exit Exam serves as a comprehensive evaluation
designed to measure a graduating nursing student's readiness to successfully
pass the NCLEX-RN and enter professional clinical practice. This rigorous
assessment evaluates integrated clinical knowledge, clinical judgment, and
safe, competent care across diverse healthcare settings. Utilizing a
sophisticated multiple-choice and scenario-based structure, the exam tests the
student's ability to prioritize nursing interventions, delegate appropriately,
manage complex patient acuities, and navigate ethical dilemmas. The emphasis
centers strictly on real-world application, critical thinking, and decisive clinical
decision-making to ensure optimal patient outcomes and professional
accountability.
SECTION ONE: QUESTIONS 1–100
A nurse is caring for a client admitted with diabetic ketoacidosis (DKA).
Which of the following initial prescriptions should the nurse anticipate
implementing first?
A. Administer regular insulin 10 units IV bolus
B. Initiate an intravenous infusion of 0.9% sodium chloride
C. Administer sodium bicarbonate 50 mEq IV
D. Obtain a glycosylated hemoglobin (HbA1c) level
🟢 B. Initiate an intravenous infusion of 0.9% sodium chloride
🔴 Explanation: Fluid resuscitation is the absolute first priority in
managing DKA to restore intravascular volume and tissue perfusion
,before administering insulin, which can precipitate a rapid drop in
potassium and fluid volume.
A nurse is assessing a client who is 2 hours post-thyroidectomy. Which of
the following findings requires immediate notification of the primary
healthcare provider?
A. Report of mild incisional pain at the surgical site
B. Soft, high-pitched voice when speaking to the nurse
C. Development of stridor and noticeable muscle twitching
D. Serosanguineous drainage on the dressing measuring 2 cm
🟢 C. Development of stridor and noticeable muscle twitching
🔴 Explanation: Stridor indicates acute laryngeal edema and airway
obstruction, a medical emergency. Muscle twitching suggests
hypocalcemia due to accidental parathyroid gland damage.
An adult client diagnosed with major depressive disorder is prescribed
fluoxetine. The nurse provides education about the medication. Which
client statement indicates a need for further teaching?
A. "I should expect to feel the full therapeutic effects of this medication
within 24 to 48 hours."
B. "I must avoid taking over-the-counter NSAIDs like ibuprofen without
consulting my doctor."
C. "I will report any thoughts of self-harm or worsening depression
immediately."
D. "I should avoid abruptly stopping this medication to prevent withdrawal
symptoms."
🟢 A. "I should expect to feel the full therapeutic effects of this medication
within 24 to 48 hours."
🔴 Explanation: Selective serotonin reuptake inhibitors (SSRIs) like
fluoxetine typically require 2 to 4 weeks, and sometimes up to 6 weeks, to
achieve full therapeutic efficacy.
A nurse is preparing to administer digoxin to a client with heart failure. The
apical pulse rate is measured at 52 beats per minute. What is the correct
nursing action?
A. Administer the prescribed dose and document the pulse rate
B. Withhold the dose and notify the primary healthcare provider
C. Recheck the pulse rate in 30 minutes and administer if greater than 60
D. Administer half of the prescribed dose and recheck vital signs
🟢 B. Withhold the dose and notify the primary healthcare provider
🔴 Explanation: Digoxin should be withheld if the adult client's apical
pulse is less than 60 beats per minute to prevent severe bradycardia and
digitalis toxicity.
,A nurse enters a client's room and finds the client unresponsive,
pulseless, and not breathing. After calling for emergency assistance and
retrieving the emergency cart, what is the next immediate nursing action?
A. Administer two rescue breaths using a bag-valve-mask device
B. Locate the carotid pulse for no more than 10 seconds
C. Begin high-quality chest compressions at a rate of 100 to 120 per
minute
D. Attach the automated external defibrillator pads
🟢 C. Begin high-quality chest compressions at a rate of 100 to 120 per
minute
🔴 Explanation: According to basic life support guidelines, establishing
immediate chest compressions minimizes delay in circulating oxygenated
blood to vital organs.
A community health nurse is planning an educational program for older
adults regarding osteoporosis prevention. Which of the following dietary
modifications should the nurse emphasize?
A. Increasing consumption of iron-rich organ meats
B. Consuming adequate amounts of calcium and vitamin D
C. Eliminating all dietary carbohydrates and sugars
D. Doubling daily protein intake through red meat consumption
🟢 B. Consuming adequate amounts of calcium and vitamin D
🔴 Explanation: Calcium and vitamin D are vital for maintaining bone
mineral density and preventing the progression of osteoporosis in older
adults.
A nurse is caring for a client with a newly placed chest tube connected to
a water-seal drainage system. The nurse notices continuous bubbling in
the water-seal chamber. What is the priority nursing action?
A. Document the finding as a normal expected outcome
B. Lower the drainage system below the level of the client's chest
C. Inspect the entire tubing system carefully for an air leak
D. Strip the chest tube vigorously to dislodge any clots
🟢 C. Inspect the entire tubing system carefully for an air leak
🔴 Explanation: Continuous bubbling in the water-seal chamber indicates
an air leak within the system or at the insertion site, which must be located
and resolved immediately.
A client is receiving a blood transfusion and develops lower back pain,
chills, and dark urine after 15 minutes of infusion. Which action should the
nurse take first?
A. Slow the rate of the blood transfusion by half
B. Stop the transfusion immediately and disconnect the tubing
C. Administer the prescribed diphenhydramine hydrochloride
D. Collect a blood sample for kidney function testing
, 🟢 B. Stop the transfusion immediately and disconnect the tubing
🔴 Explanation: These symptoms indicate an acute hemolytic transfusion
reaction. The transfusion must be stopped immediately, and the line kept
open with normal saline using new tubing.
A nurse is planning care for a client diagnosed with obsessive-compulsive
disorder (OCD) who engages in frequent handwashing rituals. Which
nursing intervention is most appropriate during the initial phase of care?
A. Prevent the client from performing the ritual to promote behavioral
extinction
B. Allow time for the ritual while gradually setting limits on the behavior
C. Confront the client about the irrational nature of the handwashing
D. Restrict the client to the room to reduce environmental triggers
🟢 B. Allow time for the ritual while gradually setting limits on the behavior
🔴 Explanation: Abruptly stopping a ritual increases anxiety significantly.
Allowing time initially while setting structured limits helps reduce anxiety
safely while working toward behavior modification.
A nurse is reviewing lab results for a client receiving heparin therapy via
continuous intravenous infusion. Which laboratory value should the nurse
monitor to evaluate the effectiveness of this therapy?
A. Prothrombin time (PT)
B. International Normalized Ratio (INR)
C. Activated partial thromboplastin time (aPTT)
D. Platelet count
🟢 C. Activated partial thromboplastin time (aPTT)
🔴 Explanation: The aPTT is specifically used to monitor the therapeutic
efficacy of unfractionated heparin therapy, adjusting the infusion rate per
established protocols.
A nurse is assessing a client with suspected appendicitis. Which of the
following findings is characteristic of this condition?
A. Pain located in the left upper quadrant radiating to the shoulder
B. Rebound tenderness located at McBurney's point
C. Severe cramping pain relieved completely by defecation
D. Constant dull ache in the suprapubic region during urination
🟢 B. Rebound tenderness located at McBurney's point
🔴 Explanation: Appendicitis classically presents with right lower quadrant
abdominal pain, specifically localized at McBurney's point, accompanied
by rebound tenderness.
A nurse is caring for an older adult client who exhibits signs of acute
delirium. Which of the following interventions should be included in the
care plan?
A. Restrain all four extremities to prevent accidental falls
