HESI RN Exit V2 EXAM LATEST 160 QUESTIONS AND
100- Verified ANSWERS JUST RELEASED
Section 1: Safety & Infection Control
1. A nurse is preparing to administer medications to a client. Which action
should the nurse take FIRST to ensure client safety?
A. Check the client's allergy band
B. Verify the client's identity using two identifiers
C. Review the medication administration record (MAR)
D. Perform hand hygiene
Answer: B. Verify the client's identity using two identifiers
Rationale: According to the National Patient Safety Goals, verifying client identity
using two unique identifiers (e.g., name and date of birth) is the FIRST critical step
before any medication administration to prevent wrong-patient errors.
2. When entering a client's room to administer an 0900 IV antibiotic, the nurse
finds that the client is engaged in sexual activity with a visitor. Which action
should the nurse implement?
A. Tell the client to stop the inappropriate behavior
B. Complete an unusual occurrence report
C. Leave the room and close the door quietly
D. Ignore the behavior and hang the IV antibiotic
Answer: C. Leave the room and close the door quietly
Rationale: The nurse should respect the client's privacy and dignity. Leaving the
room quietly and returning later respects the client's autonomy and right to
privacy.
,3. A client is prescribed 1000 mL of 0.9% sodium chloride to infuse over 8 hours.
The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute
should the nurse set the infusion?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 63 gtt/min
Answer: B. 31 gtt/min
Rationale: (1000 × 15) ÷ (8 × 60) = 15,000 ÷ 480 = 31.25 → round to 31 gtt/min.
4. After an in-service about electronic health record (EHR) security, the nurse
observes a colleague going home with printed copies of client information in a
uniform pocket. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility
B. Warn the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse
Answer: A. File a detailed incident report with the specific hiring facility
Rationale: Maintaining patient confidentiality is critical. The observed behavior
poses a serious breach of confidentiality. Filing an incident report allows the
organization to address the breach comprehensively and is required for HIPAA
compliance.
5. Which action by the nurse demonstrates proper technique when donning
sterile gloves?
A. Touching the outside of the glove with bare hands to adjust fit
B. Picking up the second glove by grasping the folded cuff edge with the gloved
hand
,C. Allowing gloved hands to drop below waist level during procedure
D. Using the dominant hand to pick up the first glove by the cuff
Answer: B. Picking up the second glove by grasping the folded cuff edge with the
gloved hand
Rationale: When donning sterile gloves, the first glove is picked up by the cuff with
the bare hand. The second glove is picked up by sliding gloved fingers under the
folded cuff.
6. A client with dysphagia is prescribed a mechanical soft diet. Which food
should the nurse offer?
A. Whole grapes
B. Chunky peanut butter
C. Mashed potatoes
D. Raw carrots
Answer: C. Mashed potatoes
Rationale: Mechanical soft diets require foods that are soft, moist, and easily
chewed/swallowed. Mashed potatoes meet these criteria. Whole grapes, chunky
peanut butter, and raw carrots pose aspiration risks.
7. The nurse is assessing a client's pain. Which statement by the client requires
IMMEDIATE intervention?
A. "My pain is a 7 out of 10."
B. "The pain feels like a sharp stabbing in my chest."
C. "I've had this ache for three days."
D. "The pain worsens when I move."
Answer: B. "The pain feels like a sharp stabbing in my chest."
Rationale: Sharp, stabbing chest pain is an emergency symptom that may indicate
myocardial infarction, pulmonary embolism, or other life-threatening conditions
requiring immediate intervention.
, 8. An older adult with atrial fibrillation fell at home and fractured the left hip.
Currently on warfarin 5 mg daily, INR is 5.0 on admission. Which prescription is
expected?
A. Administer vitamin K injection
B. Begin IV heparin infusion
C. Continue warfarin at the same dose
D. Transfuse packed RBCs
Answer: A. Administer vitamin K injection
Rationale: An INR of 5.0 indicates significantly increased bleeding risk. Vitamin K
helps reverse elevated INR.
9. A client with leukemia receiving myelosuppressive chemotherapy has a
platelet count of 25,000/mm³. Which intervention is most important?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain client's temperature q4 hours
Answer: A. Assess urine and stool for occult blood
Rationale: Thrombocytopenia (platelet count < 50,000/mm³) places the client at
significant bleeding risk. Assessing for occult blood in urine and stool is crucial for
early detection of bleeding.
10. Following a total knee replacement, a client is discharged with warfarin. The
client tells the nurse he will avoid foods high in potassium, such as bananas and
melon. How should the nurse respond?
A. Discuss necessary fluid restrictions as well as food restrictions
B. Explain that no dietary restrictions are needed with warfarin
100- Verified ANSWERS JUST RELEASED
Section 1: Safety & Infection Control
1. A nurse is preparing to administer medications to a client. Which action
should the nurse take FIRST to ensure client safety?
A. Check the client's allergy band
B. Verify the client's identity using two identifiers
C. Review the medication administration record (MAR)
D. Perform hand hygiene
Answer: B. Verify the client's identity using two identifiers
Rationale: According to the National Patient Safety Goals, verifying client identity
using two unique identifiers (e.g., name and date of birth) is the FIRST critical step
before any medication administration to prevent wrong-patient errors.
2. When entering a client's room to administer an 0900 IV antibiotic, the nurse
finds that the client is engaged in sexual activity with a visitor. Which action
should the nurse implement?
A. Tell the client to stop the inappropriate behavior
B. Complete an unusual occurrence report
C. Leave the room and close the door quietly
D. Ignore the behavior and hang the IV antibiotic
Answer: C. Leave the room and close the door quietly
Rationale: The nurse should respect the client's privacy and dignity. Leaving the
room quietly and returning later respects the client's autonomy and right to
privacy.
,3. A client is prescribed 1000 mL of 0.9% sodium chloride to infuse over 8 hours.
The IV tubing has a drop factor of 15 gtt/mL. At how many drops per minute
should the nurse set the infusion?
A. 21 gtt/min
B. 31 gtt/min
C. 42 gtt/min
D. 63 gtt/min
Answer: B. 31 gtt/min
Rationale: (1000 × 15) ÷ (8 × 60) = 15,000 ÷ 480 = 31.25 → round to 31 gtt/min.
4. After an in-service about electronic health record (EHR) security, the nurse
observes a colleague going home with printed copies of client information in a
uniform pocket. Which action should the nurse take?
A. File a detailed incident report with the specific hiring facility
B. Warn the colleague that their actions are unprofessional
C. Comment anonymously about the action on a staff discussion board
D. Communicate the colleague's actions to the unit charge nurse
Answer: A. File a detailed incident report with the specific hiring facility
Rationale: Maintaining patient confidentiality is critical. The observed behavior
poses a serious breach of confidentiality. Filing an incident report allows the
organization to address the breach comprehensively and is required for HIPAA
compliance.
5. Which action by the nurse demonstrates proper technique when donning
sterile gloves?
A. Touching the outside of the glove with bare hands to adjust fit
B. Picking up the second glove by grasping the folded cuff edge with the gloved
hand
,C. Allowing gloved hands to drop below waist level during procedure
D. Using the dominant hand to pick up the first glove by the cuff
Answer: B. Picking up the second glove by grasping the folded cuff edge with the
gloved hand
Rationale: When donning sterile gloves, the first glove is picked up by the cuff with
the bare hand. The second glove is picked up by sliding gloved fingers under the
folded cuff.
6. A client with dysphagia is prescribed a mechanical soft diet. Which food
should the nurse offer?
A. Whole grapes
B. Chunky peanut butter
C. Mashed potatoes
D. Raw carrots
Answer: C. Mashed potatoes
Rationale: Mechanical soft diets require foods that are soft, moist, and easily
chewed/swallowed. Mashed potatoes meet these criteria. Whole grapes, chunky
peanut butter, and raw carrots pose aspiration risks.
7. The nurse is assessing a client's pain. Which statement by the client requires
IMMEDIATE intervention?
A. "My pain is a 7 out of 10."
B. "The pain feels like a sharp stabbing in my chest."
C. "I've had this ache for three days."
D. "The pain worsens when I move."
Answer: B. "The pain feels like a sharp stabbing in my chest."
Rationale: Sharp, stabbing chest pain is an emergency symptom that may indicate
myocardial infarction, pulmonary embolism, or other life-threatening conditions
requiring immediate intervention.
, 8. An older adult with atrial fibrillation fell at home and fractured the left hip.
Currently on warfarin 5 mg daily, INR is 5.0 on admission. Which prescription is
expected?
A. Administer vitamin K injection
B. Begin IV heparin infusion
C. Continue warfarin at the same dose
D. Transfuse packed RBCs
Answer: A. Administer vitamin K injection
Rationale: An INR of 5.0 indicates significantly increased bleeding risk. Vitamin K
helps reverse elevated INR.
9. A client with leukemia receiving myelosuppressive chemotherapy has a
platelet count of 25,000/mm³. Which intervention is most important?
A. Assess urine and stool for occult blood
B. Monitor for signs of activity intolerance
C. Require visitors to wear respiratory masks
D. Obtain client's temperature q4 hours
Answer: A. Assess urine and stool for occult blood
Rationale: Thrombocytopenia (platelet count < 50,000/mm³) places the client at
significant bleeding risk. Assessing for occult blood in urine and stool is crucial for
early detection of bleeding.
10. Following a total knee replacement, a client is discharged with warfarin. The
client tells the nurse he will avoid foods high in potassium, such as bananas and
melon. How should the nurse respond?
A. Discuss necessary fluid restrictions as well as food restrictions
B. Explain that no dietary restrictions are needed with warfarin
