HESI PN EXIT EXAM PREPARATION WITH COMPLETE
QUESTIONS AND CORRECT ANSWERS WITH RATIONALES |
ALREADY GRADED A+||BRAND NEW VERSION!!| NURSING
HESI PREP
SECTION 1: FUNDAMENTALS OF NURSING (Questions 1–40)
1. A client with pneumonia has a fever of 103°F (39.4°C). Which intervention
should the nurse implement first?
A. Administer acetaminophen
B. Remove excess blankets
C. Apply a cooling blanket
D. Increase oral fluids
Answer: B. Remove excess blankets
Rationale: The first-line, least invasive intervention for fever is to remove external
sources of insulation to promote heat dissipation through radiation and
convection. After this non-pharmacological measure, if the fever persists, the
nurse should administer an antipyretic such as acetaminophen (A). A cooling
blanket (C) is a more aggressive intervention used for severe hyperthermia and is
not the first choice. Increasing oral fluids (D) is important to prevent dehydration
but is not the immediate priority for reducing the fever itself.
2. A nurse is assessing a client with a chest tube after thoracic surgery. The water
seal chamber has continuous bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B. Check for an air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in
the chest tube system. The nurse should first assess the entire system for loose
1
,connections, cracks, or disconnections. Documenting as normal (A) is incorrect
because continuous bubbling is never normal (intermittent bubbling with
exhalation or coughing may be normal). Clamping the chest tube immediately (C)
is dangerous because it can lead to a tension pneumothorax. Increasing suction
pressure (D) will not fix an air leak and can cause further tissue damage.
3. A client with type 2 diabetes has a fasting blood glucose of 180 mg/dL and a
hemoglobin A1c of 8.5%. Which action should the nurse take first?
A. Teach the client about insulin administration
B. Assess the client's current medication adherence and dietary patterns
C. Notify the healthcare provider for an insulin prescription
D. Instruct the client to check blood glucose four times daily
Answer: B. Assess the client's current medication adherence and dietary
patterns
Rationale: Before making any changes to the treatment plan, the nurse must first
perform a thorough assessment. An A1c of 8.5% indicates poor glycemic control
over the past 2–3 months (target is usually <7%). The nurse should assess why the
glucose is elevated—non-adherence, dietary indiscretion, lack of exercise, stress,
or illness. Teaching about insulin (A) may be premature. Notifying the provider (C)
is important, but the nurse must have assessment data to report first. Instructing
the client to check blood glucose (D) is appropriate but not the first action.
4. A client is admitted with a WBC count of 85,000. Which action should the
practical nurse (PN) take first?
A. Place the client in a private room
B. Assess for signs of infection
C. Notify the healthcare provider
D. Obtain a repeat blood sample
Answer: B. Assess for signs of infection
Rationale: A WBC count of 85,000 is critically elevated and may indicate leukemia
or severe infection. The nurse's first action is to assess the client for signs of
2
,infection (fever, chills, malaise) and other symptoms. Placing the client in a private
room (A) may be appropriate for protective isolation but is not the first
assessment priority. Notifying the provider (C) comes after assessment data is
collected. Obtaining a repeat sample (D) is not the nurse's responsibility without a
provider order.
5. A practical nurse is preparing to transfer a patient from the bed to a wheelchair.
Which action demonstrates correct body mechanics?
A. Bend at the waist with knees straight to lower the patient
B. Keep the load close to the body and bend at the knees and hips
C. Twist the torso while lifting to position the patient in the chair
D. Stand with feet close together for a narrow base of support
Answer: B. Keep the load close to the body and bend at the knees and hips
Rationale: Keeping the load close to the body and bending at the knees and hips
(not the waist) is the correct body mechanics technique. This uses the large
muscles of the legs and reduces strain on the lower back. Bending at the waist (A)
shifts strain to the lumbar spine. Twisting while lifting (C) is the most common
cause of back injury in healthcare. Standing with feet close together (D) provides a
narrow base of support, reducing stability.
6. A PN is caring for a client who requires hand hygiene and infection control.
What is the priority nursing action?
A. Implement the evidence-based nursing intervention and monitor the client's
response
B. Delay the action until the end of the shift
C. Ask an unlicensed assistant to perform the skilled assessment independently
D. Document the finding without taking further action
Answer: A. Implement the evidence-based nursing intervention and monitor the
client's response
3
, Rationale: The correct action follows the nursing process and prioritizes client
safety using evidence-based practice. The incorrect options either delay necessary
care, violate scope of practice, or fail to address the clinical need.
7. During morning assessment, a PN notes findings related to vital signs. The client
is stable but requires timely intervention. Which action should the nurse take
first?
A. Increase the frequency of vital signs without addressing the underlying issue
B. Notify the registered nurse and implement appropriate safety measures
immediately
C. Continue with the current plan and reassess only if the client complains
D. Instruct the family to manage the situation without nursing involvement
Answer: B. Notify the registered nurse and implement appropriate safety
measures immediately
Rationale: Priority is given to interventions that protect the client from immediate
harm. The other choices postpone action, ignore assessment findings, or
inappropriately shift responsibility.
8. A client on the unit needs assistance with pain assessment using a numeric
scale. What is the most appropriate next step?
A. Allow the client to refuse all assessment without documenting the refusal
B. Perform the procedure without explaining it to the client
C. Follow facility protocol and use standard precautions while performing the skill
D. Skip the verification steps to save time during a busy shift
Answer: C. Follow facility protocol and use standard precautions while
performing the skill
Rationale: Safe nursing practice requires verification, proper technique, and
communication. Skipping steps or failing to involve the client increases the risk of
error and adverse outcomes.
9. The charge nurse assigns a PN to manage intake and output measurement for
an assigned client. Which intervention is correct?
4
QUESTIONS AND CORRECT ANSWERS WITH RATIONALES |
ALREADY GRADED A+||BRAND NEW VERSION!!| NURSING
HESI PREP
SECTION 1: FUNDAMENTALS OF NURSING (Questions 1–40)
1. A client with pneumonia has a fever of 103°F (39.4°C). Which intervention
should the nurse implement first?
A. Administer acetaminophen
B. Remove excess blankets
C. Apply a cooling blanket
D. Increase oral fluids
Answer: B. Remove excess blankets
Rationale: The first-line, least invasive intervention for fever is to remove external
sources of insulation to promote heat dissipation through radiation and
convection. After this non-pharmacological measure, if the fever persists, the
nurse should administer an antipyretic such as acetaminophen (A). A cooling
blanket (C) is a more aggressive intervention used for severe hyperthermia and is
not the first choice. Increasing oral fluids (D) is important to prevent dehydration
but is not the immediate priority for reducing the fever itself.
2. A nurse is assessing a client with a chest tube after thoracic surgery. The water
seal chamber has continuous bubbling. What should the nurse do?
A. Document as normal
B. Check for an air leak
C. Clamp the chest tube immediately
D. Increase suction pressure
Answer: B. Check for an air leak
Rationale: Continuous bubbling in the water seal chamber indicates an air leak in
the chest tube system. The nurse should first assess the entire system for loose
1
,connections, cracks, or disconnections. Documenting as normal (A) is incorrect
because continuous bubbling is never normal (intermittent bubbling with
exhalation or coughing may be normal). Clamping the chest tube immediately (C)
is dangerous because it can lead to a tension pneumothorax. Increasing suction
pressure (D) will not fix an air leak and can cause further tissue damage.
3. A client with type 2 diabetes has a fasting blood glucose of 180 mg/dL and a
hemoglobin A1c of 8.5%. Which action should the nurse take first?
A. Teach the client about insulin administration
B. Assess the client's current medication adherence and dietary patterns
C. Notify the healthcare provider for an insulin prescription
D. Instruct the client to check blood glucose four times daily
Answer: B. Assess the client's current medication adherence and dietary
patterns
Rationale: Before making any changes to the treatment plan, the nurse must first
perform a thorough assessment. An A1c of 8.5% indicates poor glycemic control
over the past 2–3 months (target is usually <7%). The nurse should assess why the
glucose is elevated—non-adherence, dietary indiscretion, lack of exercise, stress,
or illness. Teaching about insulin (A) may be premature. Notifying the provider (C)
is important, but the nurse must have assessment data to report first. Instructing
the client to check blood glucose (D) is appropriate but not the first action.
4. A client is admitted with a WBC count of 85,000. Which action should the
practical nurse (PN) take first?
A. Place the client in a private room
B. Assess for signs of infection
C. Notify the healthcare provider
D. Obtain a repeat blood sample
Answer: B. Assess for signs of infection
Rationale: A WBC count of 85,000 is critically elevated and may indicate leukemia
or severe infection. The nurse's first action is to assess the client for signs of
2
,infection (fever, chills, malaise) and other symptoms. Placing the client in a private
room (A) may be appropriate for protective isolation but is not the first
assessment priority. Notifying the provider (C) comes after assessment data is
collected. Obtaining a repeat sample (D) is not the nurse's responsibility without a
provider order.
5. A practical nurse is preparing to transfer a patient from the bed to a wheelchair.
Which action demonstrates correct body mechanics?
A. Bend at the waist with knees straight to lower the patient
B. Keep the load close to the body and bend at the knees and hips
C. Twist the torso while lifting to position the patient in the chair
D. Stand with feet close together for a narrow base of support
Answer: B. Keep the load close to the body and bend at the knees and hips
Rationale: Keeping the load close to the body and bending at the knees and hips
(not the waist) is the correct body mechanics technique. This uses the large
muscles of the legs and reduces strain on the lower back. Bending at the waist (A)
shifts strain to the lumbar spine. Twisting while lifting (C) is the most common
cause of back injury in healthcare. Standing with feet close together (D) provides a
narrow base of support, reducing stability.
6. A PN is caring for a client who requires hand hygiene and infection control.
What is the priority nursing action?
A. Implement the evidence-based nursing intervention and monitor the client's
response
B. Delay the action until the end of the shift
C. Ask an unlicensed assistant to perform the skilled assessment independently
D. Document the finding without taking further action
Answer: A. Implement the evidence-based nursing intervention and monitor the
client's response
3
, Rationale: The correct action follows the nursing process and prioritizes client
safety using evidence-based practice. The incorrect options either delay necessary
care, violate scope of practice, or fail to address the clinical need.
7. During morning assessment, a PN notes findings related to vital signs. The client
is stable but requires timely intervention. Which action should the nurse take
first?
A. Increase the frequency of vital signs without addressing the underlying issue
B. Notify the registered nurse and implement appropriate safety measures
immediately
C. Continue with the current plan and reassess only if the client complains
D. Instruct the family to manage the situation without nursing involvement
Answer: B. Notify the registered nurse and implement appropriate safety
measures immediately
Rationale: Priority is given to interventions that protect the client from immediate
harm. The other choices postpone action, ignore assessment findings, or
inappropriately shift responsibility.
8. A client on the unit needs assistance with pain assessment using a numeric
scale. What is the most appropriate next step?
A. Allow the client to refuse all assessment without documenting the refusal
B. Perform the procedure without explaining it to the client
C. Follow facility protocol and use standard precautions while performing the skill
D. Skip the verification steps to save time during a busy shift
Answer: C. Follow facility protocol and use standard precautions while
performing the skill
Rationale: Safe nursing practice requires verification, proper technique, and
communication. Skipping steps or failing to involve the client increases the risk of
error and adverse outcomes.
9. The charge nurse assigns a PN to manage intake and output measurement for
an assigned client. Which intervention is correct?
4
