HESI PN EXIT Exam | ACTUAL EXAM |
Complete Exit Exam Questions & Verified
Answers | Latest Update
The nurse is assessing a client with a stage II pressure ulcer on the coccyx. Which finding
requires immediate intervention?
A. Serous drainage
B. Warmth at the site
C. Slough present
D. Fever 38.5 °C (101.3 °F)
Correct Answer: D. Fever 38.5 °C (101.3 °F)
Rationale: Fever indicates systemic infection, the priority. Serous drainage and slough are
expected in stage II, warmth alone is not urgent.
A postoperative client receiving morphine via PCA reports nausea and a respiratory rate
of 10/min. The first nursing action is to:
A. Administer promethazine
,B. Discontinue the PCA
C. Notify the surgeon
D. Raise the head of the bed
Correct Answer: B. Discontinue the PCA
Rationale: Respiratory depression is life-threatening; stopping the opioid is the immediate
PN scope action. Antiemetics and positioning are secondary.
The PN delegates morning hygiene to an AP for a client on contact precautions. Which
instruction is essential?
A. Wear gloves only
B. Remove gloves before gown
C. Perform hand hygiene after glove removal
D. Use the same gown for the next client
Correct Answer: C. Perform hand hygiene after glove removal
Rationale: Hand hygiene breaks the chain of infection. Gloves alone are insufficient;
gown removal sequence and reuse are unsafe.
,A client with COPD receives oxygen at 4 L/min via nasal cannula and becomes
increasingly somnolent. The PN should:
A. Increase oxygen to 6 L/min
B. Switch to a simple face mask
C. Lower oxygen to 2 L/min
D. Obtain ABGs first
Correct Answer: C. Lower oxygen to 2 L/min
Rationale: High oxygen can blunt hypoxic drive in COPD; reducing flow is the
immediate PN action before labs.
A newborn’s bilirubin level is 14 mg/dL at 24 h of life. The PN anticipates which order?
A. Phototherapy
B. Exchange transfusion
C. Formula feeding
D. Phenobarbital
Correct Answer: A. Phototherapy
, Rationale: Levels >12 mg/dL in first 24 h require phototherapy per NRP. Exchange is
reserved for >25 mg/dL.
A client with heart failure is prescribed furosemide 40 mg PO daily. Which finding
indicates effectiveness?
A. Weight loss 0.5 kg in 24 h
B. Urine output 30 mL/h
C. BUN 35 mg/dL
D. Serum potassium 3.0 mEq/L
Correct Answer: A. Weight loss 0.5 kg in 24 h
Rationale: Controlled diuresis evidenced by weight loss shows therapeutic effect. Low
UOP and electrolyte loss are adverse.
The PN receives report that a client’s morning digoxin level is 2.4 ng/mL (normal 0.5–2).
The priority assessment is:
A. Apical pulse 1 min
B. Blood pressure
C. Serum potassium
Complete Exit Exam Questions & Verified
Answers | Latest Update
The nurse is assessing a client with a stage II pressure ulcer on the coccyx. Which finding
requires immediate intervention?
A. Serous drainage
B. Warmth at the site
C. Slough present
D. Fever 38.5 °C (101.3 °F)
Correct Answer: D. Fever 38.5 °C (101.3 °F)
Rationale: Fever indicates systemic infection, the priority. Serous drainage and slough are
expected in stage II, warmth alone is not urgent.
A postoperative client receiving morphine via PCA reports nausea and a respiratory rate
of 10/min. The first nursing action is to:
A. Administer promethazine
,B. Discontinue the PCA
C. Notify the surgeon
D. Raise the head of the bed
Correct Answer: B. Discontinue the PCA
Rationale: Respiratory depression is life-threatening; stopping the opioid is the immediate
PN scope action. Antiemetics and positioning are secondary.
The PN delegates morning hygiene to an AP for a client on contact precautions. Which
instruction is essential?
A. Wear gloves only
B. Remove gloves before gown
C. Perform hand hygiene after glove removal
D. Use the same gown for the next client
Correct Answer: C. Perform hand hygiene after glove removal
Rationale: Hand hygiene breaks the chain of infection. Gloves alone are insufficient;
gown removal sequence and reuse are unsafe.
,A client with COPD receives oxygen at 4 L/min via nasal cannula and becomes
increasingly somnolent. The PN should:
A. Increase oxygen to 6 L/min
B. Switch to a simple face mask
C. Lower oxygen to 2 L/min
D. Obtain ABGs first
Correct Answer: C. Lower oxygen to 2 L/min
Rationale: High oxygen can blunt hypoxic drive in COPD; reducing flow is the
immediate PN action before labs.
A newborn’s bilirubin level is 14 mg/dL at 24 h of life. The PN anticipates which order?
A. Phototherapy
B. Exchange transfusion
C. Formula feeding
D. Phenobarbital
Correct Answer: A. Phototherapy
, Rationale: Levels >12 mg/dL in first 24 h require phototherapy per NRP. Exchange is
reserved for >25 mg/dL.
A client with heart failure is prescribed furosemide 40 mg PO daily. Which finding
indicates effectiveness?
A. Weight loss 0.5 kg in 24 h
B. Urine output 30 mL/h
C. BUN 35 mg/dL
D. Serum potassium 3.0 mEq/L
Correct Answer: A. Weight loss 0.5 kg in 24 h
Rationale: Controlled diuresis evidenced by weight loss shows therapeutic effect. Low
UOP and electrolyte loss are adverse.
The PN receives report that a client’s morning digoxin level is 2.4 ng/mL (normal 0.5–2).
The priority assessment is:
A. Apical pulse 1 min
B. Blood pressure
C. Serum potassium
