HESI Rn Exit Exam Retake V1 with NGN
Questions and Verified Rationalized Answers,
100% Guarantee Pass
Q001:
Type: NGN - Extended Multiple Response
Scenario Context: Ms. Henderson, a 68-year-old female, arrives at the ED with chest pain
that started 2 hours ago while gardening. She describes it as "crushing" and rates it 8/10.
She has a history of hypertension and smoking (1 PPD x 35 years). Vital signs: BP
166/92, HR 98, RR 22, SpO2 94% on room air. She states she took her amlodipine this
morning.
Question: Which assessment findings require immediate intervention within the first 5
minutes? (Select all that apply)
Options:
A. Chest pain rating of 8/10
B. SpO2 of 94% on room air
C. Blood pressure of 166/92 mmHg
D. Pain started 2 hours ago
E. History of 35 pack-year smoking
F. Patient reports nausea without vomiting
Correct: A, B, F
Rationale:
● Answer: A, B, F
● Why (2026 Rationalization): Chest pain 8/10 requires immediate ECG, aspirin,
and nitroglycerin per 2026 AHA MI protocol. SpO2 <95% indicates hypoxemia
requiring supplemental oxygen to maintain ≥94%. Nausea is common MI
symptom indicating vagal stimulation or inferior wall involvement and requires
antiemetic preparation. Blood pressure can be addressed after primary
interventions. Pain onset 2 hours ago is within PCI window but not an immediate
5-minute action item. Smoking history is risk factor for plan, not immediate
intervention.
, ● Errors: Selecting C prioritizes BP over oxygenation and pain. D and E are
historical data points requiring plan modification but not immediate 5-minute
actions.
Q002:
Type: NGN - Matrix
Scenario Context: Mr. Chen, a 45-year-old male, is post-op day 1 from exploratory
laparotomy. He has a nasogastric tube to low intermittent suction, a Foley catheter, and a
peripheral IV. He reports pain of 6/10 and wants to ambulate to the chair.
Question: Classify each action as Priority Action, Secondary Action, or Contraindicated
for this patient at this time.
Options:
A. Administer IV opioids before ambulation
B. Ambulate patient immediately without assistance
C. Assess abdomen and bowel sounds
D. Disconnect NG suction for ambulation
E. Lower bed to chair position
F. Check orthostatic vital signs
Correct: A=Priority Action, B=Contraindicated, C=Secondary Action,
D=Contraindicated, E=Secondary Action, F=Priority Action
Rationale:
● Answer: A=Priority Action, B=Contraindicated, C=Secondary Action,
D=Contraindicated, E=Secondary Action, F=Priority Action
● Why (2026 Rationalization): Pain must be controlled to 3/10 before ambulation to
prevent vagal response and ensure cooperation (ASPAN 2026). Orthostatic vitals
must be assessed due to potential hypovolemia from NGT suction and NPO status.
Ambulating without assistance is unsafe due to weakness and multiple lines. NG
suction must remain connected during ambulation—disconnecting eliminates
purpose. Abdomen assessment is important but secondary to safety for
ambulation. Bed positioning is secondary to physiological readiness.
● Errors: B violates safety protocols. D compromises therapeutic intervention and
risks aspiration.
Q003:
Type: Stand-Alone
,Scenario Context: An 89-year-old nursing home resident with dementia is admitted with
dehydration and a stage 3 pressure injury on her sacrum. She is agitated and trying to
climb out of bed despite bilateral wrist restraints ordered by provider.
Question: What is the nurse's priority action?
Options:
A. Apply additional soft mittens to prevent self-harm
B. Use bed alarm and one-to-one observation instead of restraints
C. Administer PRN haloperidol for agitation
D. Document that restraints are preventing falls
Correct: B
Rationale:
● Answer: B
● Why (2026 Rationalization): CMS 2026 restraint regulations mandate
de-escalation and least-restrictive interventions first. One-to-one observation
addresses underlying cause of agitation (potentially pain, dehydration, unfamiliar
environment) while maintaining safety. Physical restraints increase agitation,
injury, and death risk in elderly. Haloperidol increases stroke risk in dementia and
doesn't address safety. Documentation does not replace clinical intervention.
● Errors: A adds more restraint without assessment. C chemical restraint without
trying behavioral interventions. D is documentation of ineffective intervention.
Q004:
Type: NGN - Bowtie
Scenario Context: Ms. Rodriguez, a 32-year-old G2P1 at 34 weeks gestation, presents
with severe headache, visual disturbances, and epigastric pain. BP 178/110, urine protein
3+, DTRs 3+ with clonus.
Question: Complete the bowtie by selecting: (1) Priority Nursing Diagnosis, (2)
Immediate Intervention, (3) Complication to Monitor.
Options:
A. Deficient Knowledge
B. Risk for Seizure Activity
C. Administer hydralazine IV per order
D. Prepare for immediate cesarean section
E. Eclampsia
F. Severe Preeclampsia
Correct: B, C, E
Rationale:
, ● Answer: B, C, E
● Why (2026 Rationalization): Severe preeclampsia symptoms with hyperreflexia
and clonus indicate Risk for Seizure Activity (cortical irritability). Immediate BP
control with hydralazine prevents cerebral vascular accident. Eclampsia (seizure)
is immediate life-threatening complication to monitor. Deficient Knowledge is
present but not priority over safety. Cesarean may be needed but stabilization is
first. Severe preeclampsia is current diagnosis, not complication to monitor.
● Errors: A priority is physiological not educational. D premature without
stabilization. F misclassified as complication rather than current condition.
Q005:
Type: NGN - Drag-and-Drop
Scenario Context: The nurse is assigning post-operative patients to three RNs and one
LPN for the upcoming shift. Patient A: Stable post-cholecystectomy, POD #2. Patient B:
Fresh post-op craniotomy, frequent neuro checks q15min. Patient C: Post-cardiac
catheterization via femoral access, bedrest 6 hours. Patient D: Diabetic patient with new
insulin pump training. Patient E: Sepsis patient on continuous IV antibiotics with stable
vitals.
Question: Drag each patient to the appropriate caregiver.
Options:
A. Patient A → LPN
B. Patient B → RN Team Lead
C. Patient C → RN
D. Patient D → RN
E. Patient E → LPN
Correct: A, B, C, D
Rationale:
● Answer: A, B, C, D
● Why (2026 Rationalization): Per 2026 delegation guidelines and state NPA, LPN
can care for stable post-op patients with predictable outcomes. RN required for
complex neuro assessment, post-cath assessment with potential complications, and
patient education/insulin pump management requiring teaching. Sepsis on
continuous IV antibiotics requires RN assessment of response and titration.
● Errors: Assigning Patients B, C, D, or E to LPN would exceed scope of practice
and compromise patient safety.
Q006:
Questions and Verified Rationalized Answers,
100% Guarantee Pass
Q001:
Type: NGN - Extended Multiple Response
Scenario Context: Ms. Henderson, a 68-year-old female, arrives at the ED with chest pain
that started 2 hours ago while gardening. She describes it as "crushing" and rates it 8/10.
She has a history of hypertension and smoking (1 PPD x 35 years). Vital signs: BP
166/92, HR 98, RR 22, SpO2 94% on room air. She states she took her amlodipine this
morning.
Question: Which assessment findings require immediate intervention within the first 5
minutes? (Select all that apply)
Options:
A. Chest pain rating of 8/10
B. SpO2 of 94% on room air
C. Blood pressure of 166/92 mmHg
D. Pain started 2 hours ago
E. History of 35 pack-year smoking
F. Patient reports nausea without vomiting
Correct: A, B, F
Rationale:
● Answer: A, B, F
● Why (2026 Rationalization): Chest pain 8/10 requires immediate ECG, aspirin,
and nitroglycerin per 2026 AHA MI protocol. SpO2 <95% indicates hypoxemia
requiring supplemental oxygen to maintain ≥94%. Nausea is common MI
symptom indicating vagal stimulation or inferior wall involvement and requires
antiemetic preparation. Blood pressure can be addressed after primary
interventions. Pain onset 2 hours ago is within PCI window but not an immediate
5-minute action item. Smoking history is risk factor for plan, not immediate
intervention.
, ● Errors: Selecting C prioritizes BP over oxygenation and pain. D and E are
historical data points requiring plan modification but not immediate 5-minute
actions.
Q002:
Type: NGN - Matrix
Scenario Context: Mr. Chen, a 45-year-old male, is post-op day 1 from exploratory
laparotomy. He has a nasogastric tube to low intermittent suction, a Foley catheter, and a
peripheral IV. He reports pain of 6/10 and wants to ambulate to the chair.
Question: Classify each action as Priority Action, Secondary Action, or Contraindicated
for this patient at this time.
Options:
A. Administer IV opioids before ambulation
B. Ambulate patient immediately without assistance
C. Assess abdomen and bowel sounds
D. Disconnect NG suction for ambulation
E. Lower bed to chair position
F. Check orthostatic vital signs
Correct: A=Priority Action, B=Contraindicated, C=Secondary Action,
D=Contraindicated, E=Secondary Action, F=Priority Action
Rationale:
● Answer: A=Priority Action, B=Contraindicated, C=Secondary Action,
D=Contraindicated, E=Secondary Action, F=Priority Action
● Why (2026 Rationalization): Pain must be controlled to 3/10 before ambulation to
prevent vagal response and ensure cooperation (ASPAN 2026). Orthostatic vitals
must be assessed due to potential hypovolemia from NGT suction and NPO status.
Ambulating without assistance is unsafe due to weakness and multiple lines. NG
suction must remain connected during ambulation—disconnecting eliminates
purpose. Abdomen assessment is important but secondary to safety for
ambulation. Bed positioning is secondary to physiological readiness.
● Errors: B violates safety protocols. D compromises therapeutic intervention and
risks aspiration.
Q003:
Type: Stand-Alone
,Scenario Context: An 89-year-old nursing home resident with dementia is admitted with
dehydration and a stage 3 pressure injury on her sacrum. She is agitated and trying to
climb out of bed despite bilateral wrist restraints ordered by provider.
Question: What is the nurse's priority action?
Options:
A. Apply additional soft mittens to prevent self-harm
B. Use bed alarm and one-to-one observation instead of restraints
C. Administer PRN haloperidol for agitation
D. Document that restraints are preventing falls
Correct: B
Rationale:
● Answer: B
● Why (2026 Rationalization): CMS 2026 restraint regulations mandate
de-escalation and least-restrictive interventions first. One-to-one observation
addresses underlying cause of agitation (potentially pain, dehydration, unfamiliar
environment) while maintaining safety. Physical restraints increase agitation,
injury, and death risk in elderly. Haloperidol increases stroke risk in dementia and
doesn't address safety. Documentation does not replace clinical intervention.
● Errors: A adds more restraint without assessment. C chemical restraint without
trying behavioral interventions. D is documentation of ineffective intervention.
Q004:
Type: NGN - Bowtie
Scenario Context: Ms. Rodriguez, a 32-year-old G2P1 at 34 weeks gestation, presents
with severe headache, visual disturbances, and epigastric pain. BP 178/110, urine protein
3+, DTRs 3+ with clonus.
Question: Complete the bowtie by selecting: (1) Priority Nursing Diagnosis, (2)
Immediate Intervention, (3) Complication to Monitor.
Options:
A. Deficient Knowledge
B. Risk for Seizure Activity
C. Administer hydralazine IV per order
D. Prepare for immediate cesarean section
E. Eclampsia
F. Severe Preeclampsia
Correct: B, C, E
Rationale:
, ● Answer: B, C, E
● Why (2026 Rationalization): Severe preeclampsia symptoms with hyperreflexia
and clonus indicate Risk for Seizure Activity (cortical irritability). Immediate BP
control with hydralazine prevents cerebral vascular accident. Eclampsia (seizure)
is immediate life-threatening complication to monitor. Deficient Knowledge is
present but not priority over safety. Cesarean may be needed but stabilization is
first. Severe preeclampsia is current diagnosis, not complication to monitor.
● Errors: A priority is physiological not educational. D premature without
stabilization. F misclassified as complication rather than current condition.
Q005:
Type: NGN - Drag-and-Drop
Scenario Context: The nurse is assigning post-operative patients to three RNs and one
LPN for the upcoming shift. Patient A: Stable post-cholecystectomy, POD #2. Patient B:
Fresh post-op craniotomy, frequent neuro checks q15min. Patient C: Post-cardiac
catheterization via femoral access, bedrest 6 hours. Patient D: Diabetic patient with new
insulin pump training. Patient E: Sepsis patient on continuous IV antibiotics with stable
vitals.
Question: Drag each patient to the appropriate caregiver.
Options:
A. Patient A → LPN
B. Patient B → RN Team Lead
C. Patient C → RN
D. Patient D → RN
E. Patient E → LPN
Correct: A, B, C, D
Rationale:
● Answer: A, B, C, D
● Why (2026 Rationalization): Per 2026 delegation guidelines and state NPA, LPN
can care for stable post-op patients with predictable outcomes. RN required for
complex neuro assessment, post-cath assessment with potential complications, and
patient education/insulin pump management requiring teaching. Sepsis on
continuous IV antibiotics requires RN assessment of response and titration.
● Errors: Assigning Patients B, C, D, or E to LPN would exceed scope of practice
and compromise patient safety.
Q006:
