HESI RN Exit Examination Practice
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
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1. A nurse is caring for a client with heart failure who reports increasing
shortness of breath. Which assessment finding requires immediate
intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Pink, frothy sputum
D. Fatigue with activity
Answer: Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema,
which can rapidly compromise oxygenation and requires immediate
intervention.
2. A client with diabetes mellitus is experiencing diaphoresis, tremors, and
confusion. Which action should the nurse take first?
A. Administer regular insulin
B. Check the client's blood glucose
C. Encourage ambulation
D. Restrict oral fluids
Answer: Check the client's blood glucose
,Rationale: These findings suggest hypoglycemia. The nurse should
immediately confirm the glucose level when possible and then provide rapid-
acting carbohydrate if the client is able to swallow safely.
3. A client taking warfarin has an INR of 5.8. Which prescription should the
nurse question?
A. Hold the warfarin dose
B. Assess for bleeding
C. Administer vitamin K as prescribed
D. Administer the scheduled warfarin dose
Answer: Administer the scheduled warfarin dose
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. The scheduled warfarin dose should generally be held and the
provider notified.
4. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which oxygen saturation is generally an appropriate target for a client at
risk for chronic CO₂ retention?
A. 70%
B. 80%
C. 88%–92%
D. 99%–100%
Answer: 88%–92%
Rationale: For many COPD clients at risk for hypercapnic respiratory failure,
controlled oxygen therapy targeting approximately 88%–92% is appropriate
unless otherwise prescribed.
5. A nurse is assessing a client with suspected increased intracranial
pressure. Which finding is most concerning?
A. Headache
B. Restlessness
C. Decreased level of consciousness
D. Mild nausea
,Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening cerebral dysfunction and potentially increased intracranial
pressure.
6. A client receiving digoxin has an apical pulse of 52/min. What should the
nurse do?
A. Administer the medication
B. Hold the medication and notify the provider
C. Give the medication with food
D. Administer an additional dose
Answer: Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An apical pulse below the
commonly accepted adult threshold of 60/min warrants withholding the
medication and further evaluation.
7. A postoperative client suddenly develops dyspnea, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Hypoglycemia
D. Urinary retention
Answer: Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, and tachycardia are classic
findings of pulmonary embolism and require immediate intervention.
8. Which finding in a client receiving a blood transfusion requires the nurse
to stop the transfusion immediately?
A. Temperature increase with chills
B. Mild thirst
C. Heart rate of 78/min
D. Increased appetite
Answer: Temperature increase with chills
, Rationale: Fever and chills during a transfusion may indicate an acute
transfusion reaction. The transfusion should be stopped immediately and the
client assessed.
9. A client with potassium of 2.8 mEq/L is receiving IV potassium chloride.
Which action is appropriate?
A. Administer it by IV push
B. Infuse it using an infusion pump
C. Mix it with insulin only
D. Administer it undiluted
Answer: Infuse it using an infusion pump
Rationale: IV potassium must be diluted and administered at a controlled rate
using an infusion pump. IV potassium should never be administered by IV
push because it can cause fatal cardiac dysrhythmias.
10.A client with pneumonia has an oxygen saturation of 84%. What is the
nurse's priority action?
A. Encourage oral fluids
B. Apply supplemental oxygen
C. Obtain a dietary history
D. Assist the client with ambulation
Answer: Apply supplemental oxygen
Rationale: An oxygen saturation of 84% indicates significant hypoxemia.
Airway and breathing take priority, so supplemental oxygen should be
initiated according to the prescription/protocol.
11.A client with SIADH has a serum sodium level of 118 mEq/L. Which
finding should the nurse expect?
A. Excessive thirst with hypernatremia
B. Confusion and seizures
C. Severe hypertension only
D. Increased urine output
Answer: Confusion and seizures
Exam 100 Questions And Correct
Answers (Verified Answers) Plus
Rationales 2026 Q&A Instant
Download Pdf
1. A nurse is caring for a client with heart failure who reports increasing
shortness of breath. Which assessment finding requires immediate
intervention?
A. 2+ bilateral ankle edema
B. Weight gain of 1 kg in 24 hours
C. Pink, frothy sputum
D. Fatigue with activity
Answer: Pink, frothy sputum
Rationale: Pink, frothy sputum is a classic sign of acute pulmonary edema,
which can rapidly compromise oxygenation and requires immediate
intervention.
2. A client with diabetes mellitus is experiencing diaphoresis, tremors, and
confusion. Which action should the nurse take first?
A. Administer regular insulin
B. Check the client's blood glucose
C. Encourage ambulation
D. Restrict oral fluids
Answer: Check the client's blood glucose
,Rationale: These findings suggest hypoglycemia. The nurse should
immediately confirm the glucose level when possible and then provide rapid-
acting carbohydrate if the client is able to swallow safely.
3. A client taking warfarin has an INR of 5.8. Which prescription should the
nurse question?
A. Hold the warfarin dose
B. Assess for bleeding
C. Administer vitamin K as prescribed
D. Administer the scheduled warfarin dose
Answer: Administer the scheduled warfarin dose
Rationale: An INR of 5.8 represents excessive anticoagulation and increases
bleeding risk. The scheduled warfarin dose should generally be held and the
provider notified.
4. A client with chronic obstructive pulmonary disease is receiving oxygen.
Which oxygen saturation is generally an appropriate target for a client at
risk for chronic CO₂ retention?
A. 70%
B. 80%
C. 88%–92%
D. 99%–100%
Answer: 88%–92%
Rationale: For many COPD clients at risk for hypercapnic respiratory failure,
controlled oxygen therapy targeting approximately 88%–92% is appropriate
unless otherwise prescribed.
5. A nurse is assessing a client with suspected increased intracranial
pressure. Which finding is most concerning?
A. Headache
B. Restlessness
C. Decreased level of consciousness
D. Mild nausea
,Answer: Decreased level of consciousness
Rationale: A declining level of consciousness is an important indicator of
worsening cerebral dysfunction and potentially increased intracranial
pressure.
6. A client receiving digoxin has an apical pulse of 52/min. What should the
nurse do?
A. Administer the medication
B. Hold the medication and notify the provider
C. Give the medication with food
D. Administer an additional dose
Answer: Hold the medication and notify the provider
Rationale: Digoxin can cause bradycardia. An apical pulse below the
commonly accepted adult threshold of 60/min warrants withholding the
medication and further evaluation.
7. A postoperative client suddenly develops dyspnea, chest pain, and
tachycardia. Which complication should the nurse suspect?
A. Atelectasis
B. Pulmonary embolism
C. Hypoglycemia
D. Urinary retention
Answer: Pulmonary embolism
Rationale: Sudden dyspnea, pleuritic chest pain, and tachycardia are classic
findings of pulmonary embolism and require immediate intervention.
8. Which finding in a client receiving a blood transfusion requires the nurse
to stop the transfusion immediately?
A. Temperature increase with chills
B. Mild thirst
C. Heart rate of 78/min
D. Increased appetite
Answer: Temperature increase with chills
, Rationale: Fever and chills during a transfusion may indicate an acute
transfusion reaction. The transfusion should be stopped immediately and the
client assessed.
9. A client with potassium of 2.8 mEq/L is receiving IV potassium chloride.
Which action is appropriate?
A. Administer it by IV push
B. Infuse it using an infusion pump
C. Mix it with insulin only
D. Administer it undiluted
Answer: Infuse it using an infusion pump
Rationale: IV potassium must be diluted and administered at a controlled rate
using an infusion pump. IV potassium should never be administered by IV
push because it can cause fatal cardiac dysrhythmias.
10.A client with pneumonia has an oxygen saturation of 84%. What is the
nurse's priority action?
A. Encourage oral fluids
B. Apply supplemental oxygen
C. Obtain a dietary history
D. Assist the client with ambulation
Answer: Apply supplemental oxygen
Rationale: An oxygen saturation of 84% indicates significant hypoxemia.
Airway and breathing take priority, so supplemental oxygen should be
initiated according to the prescription/protocol.
11.A client with SIADH has a serum sodium level of 118 mEq/L. Which
finding should the nurse expect?
A. Excessive thirst with hypernatremia
B. Confusion and seizures
C. Severe hypertension only
D. Increased urine output
Answer: Confusion and seizures
