HESI RN EXIT NGN V10 QUESTIONS
WITH ANSWERS AND EXPLANATIONS
1. Which assessment cue should the nurse consider most urgent?
A. A sudden change from clear speech to slurred speech and unilateral weakness.
B. A long-standing preference for sleeping on two pillows.
C. A request for a snack before bedtime.
D. A chronic callus on the heel with intact skin.
Correct Answer: A. A sudden change from clear speech to slurred speech and unilateral weakness.
Explanation: Sudden focal neurologic changes may indicate an acute stroke and require emergency evaluation.
2. Before giving an antibiotic, the client states, “I once stopped breathing after a similar drug.” What
should the nurse do? Allergy history
Medication class Prior reaction Similar antibiotic Stopped breathing; emergency treatment required
A. Give the medication because the order is signed.
B. Tell the client the prior reaction does not matter.
C. Remove the allergy alert from the chart.
D. Hold the medication and urgently clarify the allergy history and order before administration.
Correct Answer: D. Hold the medication and urgently clarify the allergy history and order before administration.
Explanation: A history suggestive of anaphylaxis requires clarification before exposure. Allergy verification is a
core medication-safety step.
3. How should the nurse handle heavily soiled bed linen?
A. Shake it vigorously to remove debris.
B. Hold it away from the uniform, avoid shaking it, and place it in the designated container.
C. Place it on the floor temporarily.
D. Carry it against the uniform to free both hands.
Correct Answer: B. Hold it away from the uniform, avoid shaking it, and place it in the designated container.
Explanation: Minimizing agitation reduces dispersal of microorganisms and contaminated particles. Soiled linen
should be contained according to facility policy.
4. Which new finding most strongly indicates that an artificial airway may need suctioning?
A. Clear breath sounds and no secretions.
B. Normal oxygen saturation with easy breathing.
C. Coarse breath sounds with visible secretions and an ineffective cough.
D. A strong productive cough that clears secretions independently.
Correct Answer: C. Coarse breath sounds with visible secretions and an ineffective cough.
Explanation: Suctioning is performed when clinically indicated by retained secretions, ineffective cough,
abnormal breath sounds, or respiratory compromise, not on a rigid schedule alone.
5. The nurse receives four clients at change of shift. Which client should be assessed first? Change-of-shift
findings Client Key finding A New confusion; SpO2 86% RA B Requests snack C Awaiting discharge
papers D Chronic knee pain 4/10
A. A client who is newly confused and has an oxygen saturation of 86% on room air.
B. A client requesting a routine bedtime snack.
C. A client awaiting discharge papers after an uncomplicated procedure.
D. A client reporting chronic knee pain rated 4/10 that is unchanged from baseline.
Correct Answer: A. A client who is newly confused and has an oxygen saturation of 86% on room air.
Explanation: New confusion with hypoxemia may indicate acute respiratory compromise and threatens
oxygenation. Stable comfort and discharge needs can be addressed after the urgent physiologic problem.
6. A child’s bicycle helmet was involved in a significant crash. What should the parent do?
A. Continue using it until visible cracks appear.
B. Paint over any marks and reuse it.
C. Replace the helmet even if damage is not obvious.
D. Give it to a younger sibling.
Correct Answer: C. Replace the helmet even if damage is not obvious.
Explanation: A helmet can be structurally compromised after a crash and should be replaced according to safety
guidance.
,7. During nursing care, a client with placental abruption develops oozing from IV sites, low fibrinogen,
prolonged coagulation studies, and thrombocytopenia. Which complication is most likely? Coagulation
findings Finding Result Platelets 58,000/mm3 Fibrinogen Low PT/aPTT Prolonged Clinical Oozing from
IV sites
A. Normal pregnancy hypercoagulability.
B. Mild iron deficiency.
C. Physiologic leukocytosis.
D. Disseminated intravascular coagulation.
Correct Answer: D. Disseminated intravascular coagulation.
Explanation: DIC consumes platelets and clotting factors, leading to diffuse bleeding and abnormal coagulation
studies. Placental abruption is a recognized trigger.
8. At handoff, one client has developed a new decline in arousability while the other assigned clients have
stable routine needs. Which client requires immediate assessment? Current client status Client Status A
Newly difficult to arouse B Stable, needs bath C Chronic back pain D Requests TV help
A. A client whose condition changed from alert to difficult to arouse during the last 20 minutes.
B. A stable client waiting for a scheduled bath.
C. A client with chronic back pain requesting a heating pad.
D. A client asking for help choosing a television program.
Correct Answer: A. A client whose condition changed from alert to difficult to arouse during the last 20 minutes.
Explanation: An acute change from baseline suggests instability and requires prompt assessment. Stable comfort
and routine-care needs can usually wait.
9. For which client should the nurse avoid obtaining an oral temperature?
A. An alert adult who can follow directions.
B. A stable client sitting in a chair.
C. A client who has been resting quietly for 30 minutes.
D. A confused client who cannot safely keep the thermometer under the tongue.
Correct Answer: D. A confused client who cannot safely keep the thermometer under the tongue.
Explanation: Oral temperature measurement requires cooperation and the ability to safely position the device.
An alternative route is safer when the client cannot follow directions.
10. Review the transfusion-reaction data. Which complication is most likely? Transfusion reaction data
Finding Result Timing During transfusion BP 176/92 mm Hg JVD Present Lungs Diffuse crackles Fluid
balance Positive
A. Transfusion-associated circulatory overload (TACO).
B. TRALI with no volume overload signs.
C. A mild allergic rash only.
D. Acute hemolysis without respiratory findings.
Correct Answer: A. Transfusion-associated circulatory overload (TACO).
Explanation: TACO reflects transfusion-related volume overload and is associated with hypertension, elevated
venous pressure, pulmonary edema, and positive fluid balance, especially in vulnerable clients.
11. Which outcome is written in the most measurable and time-limited manner?
A. The client will improve mobility soon.
B. The client will understand walking better.
C. The client will try to be more independent.
D. The client will ambulate 50 feet with a walker and one-person standby assistance by 1400 today.
Correct Answer: D. The client will ambulate 50 feet with a walker and one-person standby assistance by 1400
today.
Explanation: A well-written outcome describes observable behavior, a measurable criterion, and a time frame.
Vague terms such as improve or understand are difficult to evaluate.
12. A motor-vehicle crash victim is unresponsive with snoring respirations and possible cervical-spine
injury. Which action takes priority?
A. Flex the neck sharply to improve visibility.
B. Open and maintain the airway using a jaw-thrust while protecting cervical alignment.
C. Delay airway care until radiographs are complete.
D. Sit the client upright and ask for a pain score.
, Correct Answer: B. Open and maintain the airway using a jaw-thrust while protecting cervical alignment.
Explanation: Airway takes priority in trauma. A jaw-thrust is used when cervical injury is suspected because it
can open the airway while minimizing neck movement.
13. A pediatric client taking digoxin develops vomiting, poor appetite, and a slower-than-usual heart rate.
What should the nurse suspect?
Medication assessment Finding Result
Medication Digoxin Heart rate Lower than usual Symptoms Vomiting, poor appetite
A. Expected therapeutic response.
B. Possible digoxin toxicity.
C. Iron deficiency only.
D. Croup.
Correct Answer: B. Possible digoxin toxicity.
Explanation: GI symptoms and bradycardia can indicate digoxin toxicity and should prompt evaluation and
withholding according to ordered parameters.
14. What is the nurse's role when witnessing a client's signature on a procedure consent form?
A. Provide a new detailed explanation of all procedural risks instead of the provider.
B. Verify that the signature is voluntary and belongs to the client, and notify the provider if the client has
unanswered questions.
C. Sign for the client if the client is anxious.
D. Guarantee the outcome of the procedure.
Correct Answer: B. Verify that the signature is voluntary and belongs to the client, and notify the provider if the
client has unanswered questions.
Explanation: The provider performing the procedure is responsible for the informed-consent discussion. The
nurse may witness the signature and should stop the process if the client lacks understanding or is being coerced.
15. After reviewing the situation involving Hemorrhagic stroke, which action should the nurse prioritize?
A. Protect the airway, provide oxygen, obtain IV access, and administer rapid-acting antiseizure medication per
emergency protocol.
B. Determine last-known-well time, activate the stroke pathway, check glucose, and obtain urgent brain imaging.
C. Protect airway and neurologic status, control blood pressure as ordered, and reverse anticoagulation when
indicated.
D. Sit the client upright, loosen restrictive items, and rapidly identify and remove the trigger, especially bladder
distention or bowel impaction.
Correct Answer: C. Protect airway and neurologic status, control blood pressure as ordered, and reverse
anticoagulation when indicated.
Explanation: This action addresses the highest-priority risk in Hemorrhagic stroke. Intracranial bleeding causes
tissue injury and may rapidly raise ICP; management differs from ischemic stroke and may require blood-pressure
control and reversal of anticoagulation.
16. During a shift, a client is on postoperative day 1 after abdominal surgery and has no contraindication to
mobility. Which intervention best reduces venous thromboembolism risk?
A. Place a pillow directly behind both knees for comfort.
B. Assist the client to ambulate early and regularly.
C. Keep the client on strict bed rest until bowel sounds return.
D. Massage the calves every 4 hours.
Correct Answer: B. Assist the client to ambulate early and regularly.
Explanation: Early ambulation promotes venous return and reduces stasis. Calf massage is inappropriate when
thrombosis is possible, and prolonged bed rest increases risk.
17. Which medication should a school-age child with asthma use for rapid relief of acute bronchospasm?
A. An inhaled corticosteroid used only once during an attack.
B. A leukotriene modifier as the sole emergency treatment.
C. A short-acting inhaled beta2-agonist.
D. An oral antihistamine as the primary bronchodilator.
Correct Answer: C. A short-acting inhaled beta2-agonist.
Explanation: Short-acting beta2-agonists provide rapid bronchodilation during acute symptoms. Controller
WITH ANSWERS AND EXPLANATIONS
1. Which assessment cue should the nurse consider most urgent?
A. A sudden change from clear speech to slurred speech and unilateral weakness.
B. A long-standing preference for sleeping on two pillows.
C. A request for a snack before bedtime.
D. A chronic callus on the heel with intact skin.
Correct Answer: A. A sudden change from clear speech to slurred speech and unilateral weakness.
Explanation: Sudden focal neurologic changes may indicate an acute stroke and require emergency evaluation.
2. Before giving an antibiotic, the client states, “I once stopped breathing after a similar drug.” What
should the nurse do? Allergy history
Medication class Prior reaction Similar antibiotic Stopped breathing; emergency treatment required
A. Give the medication because the order is signed.
B. Tell the client the prior reaction does not matter.
C. Remove the allergy alert from the chart.
D. Hold the medication and urgently clarify the allergy history and order before administration.
Correct Answer: D. Hold the medication and urgently clarify the allergy history and order before administration.
Explanation: A history suggestive of anaphylaxis requires clarification before exposure. Allergy verification is a
core medication-safety step.
3. How should the nurse handle heavily soiled bed linen?
A. Shake it vigorously to remove debris.
B. Hold it away from the uniform, avoid shaking it, and place it in the designated container.
C. Place it on the floor temporarily.
D. Carry it against the uniform to free both hands.
Correct Answer: B. Hold it away from the uniform, avoid shaking it, and place it in the designated container.
Explanation: Minimizing agitation reduces dispersal of microorganisms and contaminated particles. Soiled linen
should be contained according to facility policy.
4. Which new finding most strongly indicates that an artificial airway may need suctioning?
A. Clear breath sounds and no secretions.
B. Normal oxygen saturation with easy breathing.
C. Coarse breath sounds with visible secretions and an ineffective cough.
D. A strong productive cough that clears secretions independently.
Correct Answer: C. Coarse breath sounds with visible secretions and an ineffective cough.
Explanation: Suctioning is performed when clinically indicated by retained secretions, ineffective cough,
abnormal breath sounds, or respiratory compromise, not on a rigid schedule alone.
5. The nurse receives four clients at change of shift. Which client should be assessed first? Change-of-shift
findings Client Key finding A New confusion; SpO2 86% RA B Requests snack C Awaiting discharge
papers D Chronic knee pain 4/10
A. A client who is newly confused and has an oxygen saturation of 86% on room air.
B. A client requesting a routine bedtime snack.
C. A client awaiting discharge papers after an uncomplicated procedure.
D. A client reporting chronic knee pain rated 4/10 that is unchanged from baseline.
Correct Answer: A. A client who is newly confused and has an oxygen saturation of 86% on room air.
Explanation: New confusion with hypoxemia may indicate acute respiratory compromise and threatens
oxygenation. Stable comfort and discharge needs can be addressed after the urgent physiologic problem.
6. A child’s bicycle helmet was involved in a significant crash. What should the parent do?
A. Continue using it until visible cracks appear.
B. Paint over any marks and reuse it.
C. Replace the helmet even if damage is not obvious.
D. Give it to a younger sibling.
Correct Answer: C. Replace the helmet even if damage is not obvious.
Explanation: A helmet can be structurally compromised after a crash and should be replaced according to safety
guidance.
,7. During nursing care, a client with placental abruption develops oozing from IV sites, low fibrinogen,
prolonged coagulation studies, and thrombocytopenia. Which complication is most likely? Coagulation
findings Finding Result Platelets 58,000/mm3 Fibrinogen Low PT/aPTT Prolonged Clinical Oozing from
IV sites
A. Normal pregnancy hypercoagulability.
B. Mild iron deficiency.
C. Physiologic leukocytosis.
D. Disseminated intravascular coagulation.
Correct Answer: D. Disseminated intravascular coagulation.
Explanation: DIC consumes platelets and clotting factors, leading to diffuse bleeding and abnormal coagulation
studies. Placental abruption is a recognized trigger.
8. At handoff, one client has developed a new decline in arousability while the other assigned clients have
stable routine needs. Which client requires immediate assessment? Current client status Client Status A
Newly difficult to arouse B Stable, needs bath C Chronic back pain D Requests TV help
A. A client whose condition changed from alert to difficult to arouse during the last 20 minutes.
B. A stable client waiting for a scheduled bath.
C. A client with chronic back pain requesting a heating pad.
D. A client asking for help choosing a television program.
Correct Answer: A. A client whose condition changed from alert to difficult to arouse during the last 20 minutes.
Explanation: An acute change from baseline suggests instability and requires prompt assessment. Stable comfort
and routine-care needs can usually wait.
9. For which client should the nurse avoid obtaining an oral temperature?
A. An alert adult who can follow directions.
B. A stable client sitting in a chair.
C. A client who has been resting quietly for 30 minutes.
D. A confused client who cannot safely keep the thermometer under the tongue.
Correct Answer: D. A confused client who cannot safely keep the thermometer under the tongue.
Explanation: Oral temperature measurement requires cooperation and the ability to safely position the device.
An alternative route is safer when the client cannot follow directions.
10. Review the transfusion-reaction data. Which complication is most likely? Transfusion reaction data
Finding Result Timing During transfusion BP 176/92 mm Hg JVD Present Lungs Diffuse crackles Fluid
balance Positive
A. Transfusion-associated circulatory overload (TACO).
B. TRALI with no volume overload signs.
C. A mild allergic rash only.
D. Acute hemolysis without respiratory findings.
Correct Answer: A. Transfusion-associated circulatory overload (TACO).
Explanation: TACO reflects transfusion-related volume overload and is associated with hypertension, elevated
venous pressure, pulmonary edema, and positive fluid balance, especially in vulnerable clients.
11. Which outcome is written in the most measurable and time-limited manner?
A. The client will improve mobility soon.
B. The client will understand walking better.
C. The client will try to be more independent.
D. The client will ambulate 50 feet with a walker and one-person standby assistance by 1400 today.
Correct Answer: D. The client will ambulate 50 feet with a walker and one-person standby assistance by 1400
today.
Explanation: A well-written outcome describes observable behavior, a measurable criterion, and a time frame.
Vague terms such as improve or understand are difficult to evaluate.
12. A motor-vehicle crash victim is unresponsive with snoring respirations and possible cervical-spine
injury. Which action takes priority?
A. Flex the neck sharply to improve visibility.
B. Open and maintain the airway using a jaw-thrust while protecting cervical alignment.
C. Delay airway care until radiographs are complete.
D. Sit the client upright and ask for a pain score.
, Correct Answer: B. Open and maintain the airway using a jaw-thrust while protecting cervical alignment.
Explanation: Airway takes priority in trauma. A jaw-thrust is used when cervical injury is suspected because it
can open the airway while minimizing neck movement.
13. A pediatric client taking digoxin develops vomiting, poor appetite, and a slower-than-usual heart rate.
What should the nurse suspect?
Medication assessment Finding Result
Medication Digoxin Heart rate Lower than usual Symptoms Vomiting, poor appetite
A. Expected therapeutic response.
B. Possible digoxin toxicity.
C. Iron deficiency only.
D. Croup.
Correct Answer: B. Possible digoxin toxicity.
Explanation: GI symptoms and bradycardia can indicate digoxin toxicity and should prompt evaluation and
withholding according to ordered parameters.
14. What is the nurse's role when witnessing a client's signature on a procedure consent form?
A. Provide a new detailed explanation of all procedural risks instead of the provider.
B. Verify that the signature is voluntary and belongs to the client, and notify the provider if the client has
unanswered questions.
C. Sign for the client if the client is anxious.
D. Guarantee the outcome of the procedure.
Correct Answer: B. Verify that the signature is voluntary and belongs to the client, and notify the provider if the
client has unanswered questions.
Explanation: The provider performing the procedure is responsible for the informed-consent discussion. The
nurse may witness the signature and should stop the process if the client lacks understanding or is being coerced.
15. After reviewing the situation involving Hemorrhagic stroke, which action should the nurse prioritize?
A. Protect the airway, provide oxygen, obtain IV access, and administer rapid-acting antiseizure medication per
emergency protocol.
B. Determine last-known-well time, activate the stroke pathway, check glucose, and obtain urgent brain imaging.
C. Protect airway and neurologic status, control blood pressure as ordered, and reverse anticoagulation when
indicated.
D. Sit the client upright, loosen restrictive items, and rapidly identify and remove the trigger, especially bladder
distention or bowel impaction.
Correct Answer: C. Protect airway and neurologic status, control blood pressure as ordered, and reverse
anticoagulation when indicated.
Explanation: This action addresses the highest-priority risk in Hemorrhagic stroke. Intracranial bleeding causes
tissue injury and may rapidly raise ICP; management differs from ischemic stroke and may require blood-pressure
control and reversal of anticoagulation.
16. During a shift, a client is on postoperative day 1 after abdominal surgery and has no contraindication to
mobility. Which intervention best reduces venous thromboembolism risk?
A. Place a pillow directly behind both knees for comfort.
B. Assist the client to ambulate early and regularly.
C. Keep the client on strict bed rest until bowel sounds return.
D. Massage the calves every 4 hours.
Correct Answer: B. Assist the client to ambulate early and regularly.
Explanation: Early ambulation promotes venous return and reduces stasis. Calf massage is inappropriate when
thrombosis is possible, and prolonged bed rest increases risk.
17. Which medication should a school-age child with asthma use for rapid relief of acute bronchospasm?
A. An inhaled corticosteroid used only once during an attack.
B. A leukotriene modifier as the sole emergency treatment.
C. A short-acting inhaled beta2-agonist.
D. An oral antihistamine as the primary bronchodilator.
Correct Answer: C. A short-acting inhaled beta2-agonist.
Explanation: Short-acting beta2-agonists provide rapid bronchodilation during acute symptoms. Controller
