HESI RN EXIT V2 SET 2 EXAM QUESTIONS
WITH ANSWERS AND EXPLANATIONS
1. Which information should be included in a safe handoff report?
A. Personal opinions about the client’s personality
B. Unverified rumors from family
C. Current clinical status, recent changes, pending tests, and priority concerns
D. Only the diagnosis with no current assessment
Correct Answer: C. Current clinical status, recent changes, pending tests, and priority concerns
Rationale: Effective handoff communicates concise, relevant, current clinical information and risks needed for
continuity and safety.
2. A client with suspected measles arrives in the emergency department. Which action is priority?
A. Use droplet precautions only
B. Seat the client in the common waiting area
C. Place the client in an airborne infection isolation room
D. Use contact precautions without respiratory protection
Correct Answer: C. Place the client in an airborne infection isolation room
Rationale: Measles is highly contagious by the airborne route. Prompt airborne isolation protects other clients
and staff.
3. A client on a beta blocker has HR 48/min and dizziness before the scheduled dose. What should the nurse
do?
A. Give a double dose
B. Hold the dose and follow prescribed parameters/notify the provider
C. Administer caffeine with the medication
D. Encourage vigorous exercise first
Correct Answer: B. Hold the dose and follow prescribed parameters/notify the provider
Rationale: Symptomatic bradycardia is a reason to hold many beta blockers according to ordered parameters and
seek further direction.
4. A client reports that a staff member made an unwanted sexual comment. What is the nurse’s
responsibility?
A. Tell the client to ignore it
B. Ensure immediate safety, report through appropriate channels, and support the client
C. Confront the accused person alone without reporting
D. Delete the complaint from documentation
Correct Answer: B. Ensure immediate safety, report through appropriate channels, and support the client
Rationale: Allegations of harassment or abuse require safety, objective documentation, and reporting according
to policy and law.
5. A client receiving IV morphine is also prescribed a benzodiazepine. What is the greatest combined risk?
A. Severe hypertension
B. Hyperactivity
C. Respiratory depression and excessive sedation
D. Polycythemia
Correct Answer: C. Respiratory depression and excessive sedation
Rationale: Opioids and benzodiazepines have additive CNS and respiratory depressant effects and require careful
monitoring.
6. Which client should the nurse see first after receiving report?
A. A client with a tracheostomy who has new restlessness and noisy respirations
B. A client with chronic back pain requesting a heating pad
C. A client ready for routine discharge paperwork
D. A client with stable atrial fibrillation awaiting lunch
Correct Answer: A. A client with a tracheostomy who has new restlessness and noisy respirations
Rationale: New restlessness and noisy respirations in a tracheostomy client may signal airway obstruction and
require immediate assessment.
,7. A client on warfarin asks about vitamin K-containing foods. Which teaching is best?
A. Keep vitamin K intake reasonably consistent rather than avoiding it completely
B. Eliminate all green vegetables permanently
C. Double vitamin K intake when INR is high without guidance
D. Take vitamin K supplements with every dose
Correct Answer: A. Keep vitamin K intake reasonably consistent rather than avoiding it completely
Rationale: Consistency in vitamin K intake helps stabilize anticoagulation; abrupt dietary changes can alter INR.
8. The charge nurse is making assignments. Which client is most appropriate for a float RN from an
outpatient clinic who has completed unit orientation?
A. A client in septic shock on multiple titrated vasopressors
B. A client with a fresh tracheostomy and recurrent bleeding
C. A stable client 2 days after laparoscopic cholecystectomy
D. A client receiving alteplase for acute ischemic stroke
Correct Answer: C. A stable client 2 days after laparoscopic cholecystectomy
Rationale: A float nurse should receive a stable client with predictable care needs. High-acuity, rapidly changing
therapies require specialized recent experience.
9. A client with acute ischemic stroke is unable to speak but follows commands and appears frustrated.
Which finding best describes the problem?
A. Receptive aphasia
B. Hemianopia
C. Expressive aphasia
D. Ataxia
Correct Answer: C. Expressive aphasia
Rationale: The client understands language and commands but cannot produce speech, consistent with
expressive aphasia.
10. After caring for a client with draining MRSA wound infection, which action is essential before leaving
the room?
A. Wear the same gown to the next room
B. Remove PPE safely and perform hand hygiene
C. Carry used dressings uncovered through the hallway
D. Touch the face before glove removal
Correct Answer: B. Remove PPE safely and perform hand hygiene
Rationale: Safe PPE removal and hand hygiene reduce transmission of contact-spread organisms.
11. A client with suspected meningococcal meningitis has fever, nuchal rigidity, and a petechial rash.
Which action is priority?
A. Delay treatment until all culture results are final
B. Initiate appropriate isolation and urgent antimicrobial treatment
C. Encourage ambulation
D. Provide only oral fluids
Correct Answer: B. Initiate appropriate isolation and urgent antimicrobial treatment
Rationale: Meningococcal disease can progress rapidly; droplet precautions and prompt antibiotic therapy are
critical.
12. A client with a do-not-resuscitate order is scheduled for surgery. Which action is most appropriate?
A. Automatically cancel the DNR without discussion
B. Assume the DNR means no anesthesia may be given
C. Clarify how the existing code-status order will be handled perioperatively with the client/surrogate and
surgical team
D. Hide the DNR from the operating room team
Correct Answer: C. Clarify how the existing code-status order will be handled perioperatively with the
client/surrogate and surgical team
Rationale: Perioperative code-status plans should be explicitly reviewed rather than automatically suspended or
ignored.
13. A client with acute pancreatitis reports worsening abdominal pain, tachycardia, and new hypotension.
Which concern is most urgent?
, A. Improved pancreatic function
B. Hemodynamic instability from severe systemic inflammation or fluid shifts
C. Simple hunger
D. Constipation only
Correct Answer: B. Hemodynamic instability from severe systemic inflammation or fluid shifts
Rationale: Severe pancreatitis can cause major third-spacing, systemic inflammation, shock, and organ
dysfunction.
14. Which client is at greatest risk for a fall and should receive the most intensive prevention plan?
A. A young adult with a healed wrist fracture
B. A stable client who walks independently
C. An adult with corrected vision and no fall history
D. An older adult with delirium, orthostatic hypotension, and a recent fall
Correct Answer: D. An older adult with delirium, orthostatic hypotension, and a recent fall
Rationale: Acute confusion, orthostatic hypotension, and prior falls substantially increase fall risk.
15. A client receiving oxytocin develops uterine tachysystole with recurrent fetal decelerations. Which
nursing action is appropriate?
A. Increase oxytocin to shorten labor
B. Place the client supine
C. Stop the oxytocin infusion and begin intrauterine resuscitative measures
D. Encourage pushing before full dilation
Correct Answer: C. Stop the oxytocin infusion and begin intrauterine resuscitative measures
Rationale: Oxytocin should be stopped when tachysystole is associated with nonreassuring fetal status, while
corrective measures and provider notification occur.
16. A nurse believes a discharge plan is unsafe because the client has no way to obtain oxygen. Which
action is best?
A. Discharge the client and document concern later
B. Tell the client to borrow oxygen from a neighbor
C. Delay unsafe discharge and escalate the barrier through the interdisciplinary team
D. Remove oxygen from the plan without an order
Correct Answer: C. Delay unsafe discharge and escalate the barrier through the interdisciplinary team
Rationale: Safe discharge requires essential equipment and supports to be arranged; unresolved safety barriers
should be escalated.
17. A client with chest pain has ST-segment elevation and becomes diaphoretic and hypotensive. Which
nursing action is the priority?
A. Schedule outpatient stress testing
B. Encourage the client to walk to reduce anxiety
C. Delay treatment until cardiac enzymes return
D. Activate the emergency cardiac reperfusion pathway and support circulation
Correct Answer: D. Activate the emergency cardiac reperfusion pathway and support circulation
Rationale: ST-elevation with hemodynamic instability indicates an acute coronary occlusion requiring emergent
reperfusion and stabilization.
18. A client taking lithium reports vomiting, coarse tremor, and unsteady gait. Which action is most
appropriate?
A. Give the next dose with an antacid
B. Encourage sodium restriction
C. Reassure the client these are expected mild effects
D. Hold lithium and notify the provider
Correct Answer: D. Hold lithium and notify the provider
Rationale: GI symptoms, coarse tremor, and ataxia can indicate lithium toxicity and require holding the
medication and urgent evaluation.
19. A nurse prepares to enter the room of a client with bacterial meningitis during the first day of effective
antibiotics. Which precaution is appropriate?
A. Airborne precautions only
B. Droplet precautions
WITH ANSWERS AND EXPLANATIONS
1. Which information should be included in a safe handoff report?
A. Personal opinions about the client’s personality
B. Unverified rumors from family
C. Current clinical status, recent changes, pending tests, and priority concerns
D. Only the diagnosis with no current assessment
Correct Answer: C. Current clinical status, recent changes, pending tests, and priority concerns
Rationale: Effective handoff communicates concise, relevant, current clinical information and risks needed for
continuity and safety.
2. A client with suspected measles arrives in the emergency department. Which action is priority?
A. Use droplet precautions only
B. Seat the client in the common waiting area
C. Place the client in an airborne infection isolation room
D. Use contact precautions without respiratory protection
Correct Answer: C. Place the client in an airborne infection isolation room
Rationale: Measles is highly contagious by the airborne route. Prompt airborne isolation protects other clients
and staff.
3. A client on a beta blocker has HR 48/min and dizziness before the scheduled dose. What should the nurse
do?
A. Give a double dose
B. Hold the dose and follow prescribed parameters/notify the provider
C. Administer caffeine with the medication
D. Encourage vigorous exercise first
Correct Answer: B. Hold the dose and follow prescribed parameters/notify the provider
Rationale: Symptomatic bradycardia is a reason to hold many beta blockers according to ordered parameters and
seek further direction.
4. A client reports that a staff member made an unwanted sexual comment. What is the nurse’s
responsibility?
A. Tell the client to ignore it
B. Ensure immediate safety, report through appropriate channels, and support the client
C. Confront the accused person alone without reporting
D. Delete the complaint from documentation
Correct Answer: B. Ensure immediate safety, report through appropriate channels, and support the client
Rationale: Allegations of harassment or abuse require safety, objective documentation, and reporting according
to policy and law.
5. A client receiving IV morphine is also prescribed a benzodiazepine. What is the greatest combined risk?
A. Severe hypertension
B. Hyperactivity
C. Respiratory depression and excessive sedation
D. Polycythemia
Correct Answer: C. Respiratory depression and excessive sedation
Rationale: Opioids and benzodiazepines have additive CNS and respiratory depressant effects and require careful
monitoring.
6. Which client should the nurse see first after receiving report?
A. A client with a tracheostomy who has new restlessness and noisy respirations
B. A client with chronic back pain requesting a heating pad
C. A client ready for routine discharge paperwork
D. A client with stable atrial fibrillation awaiting lunch
Correct Answer: A. A client with a tracheostomy who has new restlessness and noisy respirations
Rationale: New restlessness and noisy respirations in a tracheostomy client may signal airway obstruction and
require immediate assessment.
,7. A client on warfarin asks about vitamin K-containing foods. Which teaching is best?
A. Keep vitamin K intake reasonably consistent rather than avoiding it completely
B. Eliminate all green vegetables permanently
C. Double vitamin K intake when INR is high without guidance
D. Take vitamin K supplements with every dose
Correct Answer: A. Keep vitamin K intake reasonably consistent rather than avoiding it completely
Rationale: Consistency in vitamin K intake helps stabilize anticoagulation; abrupt dietary changes can alter INR.
8. The charge nurse is making assignments. Which client is most appropriate for a float RN from an
outpatient clinic who has completed unit orientation?
A. A client in septic shock on multiple titrated vasopressors
B. A client with a fresh tracheostomy and recurrent bleeding
C. A stable client 2 days after laparoscopic cholecystectomy
D. A client receiving alteplase for acute ischemic stroke
Correct Answer: C. A stable client 2 days after laparoscopic cholecystectomy
Rationale: A float nurse should receive a stable client with predictable care needs. High-acuity, rapidly changing
therapies require specialized recent experience.
9. A client with acute ischemic stroke is unable to speak but follows commands and appears frustrated.
Which finding best describes the problem?
A. Receptive aphasia
B. Hemianopia
C. Expressive aphasia
D. Ataxia
Correct Answer: C. Expressive aphasia
Rationale: The client understands language and commands but cannot produce speech, consistent with
expressive aphasia.
10. After caring for a client with draining MRSA wound infection, which action is essential before leaving
the room?
A. Wear the same gown to the next room
B. Remove PPE safely and perform hand hygiene
C. Carry used dressings uncovered through the hallway
D. Touch the face before glove removal
Correct Answer: B. Remove PPE safely and perform hand hygiene
Rationale: Safe PPE removal and hand hygiene reduce transmission of contact-spread organisms.
11. A client with suspected meningococcal meningitis has fever, nuchal rigidity, and a petechial rash.
Which action is priority?
A. Delay treatment until all culture results are final
B. Initiate appropriate isolation and urgent antimicrobial treatment
C. Encourage ambulation
D. Provide only oral fluids
Correct Answer: B. Initiate appropriate isolation and urgent antimicrobial treatment
Rationale: Meningococcal disease can progress rapidly; droplet precautions and prompt antibiotic therapy are
critical.
12. A client with a do-not-resuscitate order is scheduled for surgery. Which action is most appropriate?
A. Automatically cancel the DNR without discussion
B. Assume the DNR means no anesthesia may be given
C. Clarify how the existing code-status order will be handled perioperatively with the client/surrogate and
surgical team
D. Hide the DNR from the operating room team
Correct Answer: C. Clarify how the existing code-status order will be handled perioperatively with the
client/surrogate and surgical team
Rationale: Perioperative code-status plans should be explicitly reviewed rather than automatically suspended or
ignored.
13. A client with acute pancreatitis reports worsening abdominal pain, tachycardia, and new hypotension.
Which concern is most urgent?
, A. Improved pancreatic function
B. Hemodynamic instability from severe systemic inflammation or fluid shifts
C. Simple hunger
D. Constipation only
Correct Answer: B. Hemodynamic instability from severe systemic inflammation or fluid shifts
Rationale: Severe pancreatitis can cause major third-spacing, systemic inflammation, shock, and organ
dysfunction.
14. Which client is at greatest risk for a fall and should receive the most intensive prevention plan?
A. A young adult with a healed wrist fracture
B. A stable client who walks independently
C. An adult with corrected vision and no fall history
D. An older adult with delirium, orthostatic hypotension, and a recent fall
Correct Answer: D. An older adult with delirium, orthostatic hypotension, and a recent fall
Rationale: Acute confusion, orthostatic hypotension, and prior falls substantially increase fall risk.
15. A client receiving oxytocin develops uterine tachysystole with recurrent fetal decelerations. Which
nursing action is appropriate?
A. Increase oxytocin to shorten labor
B. Place the client supine
C. Stop the oxytocin infusion and begin intrauterine resuscitative measures
D. Encourage pushing before full dilation
Correct Answer: C. Stop the oxytocin infusion and begin intrauterine resuscitative measures
Rationale: Oxytocin should be stopped when tachysystole is associated with nonreassuring fetal status, while
corrective measures and provider notification occur.
16. A nurse believes a discharge plan is unsafe because the client has no way to obtain oxygen. Which
action is best?
A. Discharge the client and document concern later
B. Tell the client to borrow oxygen from a neighbor
C. Delay unsafe discharge and escalate the barrier through the interdisciplinary team
D. Remove oxygen from the plan without an order
Correct Answer: C. Delay unsafe discharge and escalate the barrier through the interdisciplinary team
Rationale: Safe discharge requires essential equipment and supports to be arranged; unresolved safety barriers
should be escalated.
17. A client with chest pain has ST-segment elevation and becomes diaphoretic and hypotensive. Which
nursing action is the priority?
A. Schedule outpatient stress testing
B. Encourage the client to walk to reduce anxiety
C. Delay treatment until cardiac enzymes return
D. Activate the emergency cardiac reperfusion pathway and support circulation
Correct Answer: D. Activate the emergency cardiac reperfusion pathway and support circulation
Rationale: ST-elevation with hemodynamic instability indicates an acute coronary occlusion requiring emergent
reperfusion and stabilization.
18. A client taking lithium reports vomiting, coarse tremor, and unsteady gait. Which action is most
appropriate?
A. Give the next dose with an antacid
B. Encourage sodium restriction
C. Reassure the client these are expected mild effects
D. Hold lithium and notify the provider
Correct Answer: D. Hold lithium and notify the provider
Rationale: GI symptoms, coarse tremor, and ataxia can indicate lithium toxicity and require holding the
medication and urgent evaluation.
19. A nurse prepares to enter the room of a client with bacterial meningitis during the first day of effective
antibiotics. Which precaution is appropriate?
A. Airborne precautions only
B. Droplet precautions
