2026/2027 HESI EXIT EXAM V3 | NGN CASE STUDIES & ACTUAL Q&A
HESI RN Exit Examination Version 3 (V3) with Next Generation NCLEX® (NGN) Integration | Core
Domains: Advanced Clinical Judgment via NGN Items (Bow-Tie, Extended Multiple Response, Matrix),
Complex Unfolding Case Studies Across the Lifespan, Integrated Pharmacology & Pathophysiology,
Crisis Management & Emergency Response Prioritization, Health Equity & Culturally Competent Care,
Patient Education & Discharge Planning in Evolving Scenarios, and Ethical/Legal Analysis in Dynamic
Clinical Contexts | NCLEX-RN® Readiness Focus | Most Advanced NGN-Enhanced Exit Exam Format
Exam Structure
The HESI Exit Exam V3 with NGN for the 2026/2027 academic cycle is a 150-question, multiple-choice
question (MCQ) and NGN item-type examination.
Introduction
This HESI Exit Exam V3 guide for the 2026/2027 cycle represents the most advanced iteration of the
predictor exam, fully aligned with the Next Generation NCLEX® (NGN) framework. The content
emphasizes high-level clinical judgment through complex, multi-system case studies that require
synthesis of advanced nursing knowledge, sophisticated prioritization, and evidence-based
decision-making under uncertainty for optimal NCLEX-RN® readiness.
Answer Format
All correct answers and advanced clinical judgments must be presented in bold and green, followed by
detailed rationales that meticulously apply the NGN Clinical Judgment Measurement Model, integrate
complex pathophysiology and pharmacology, analyze risk-benefit in high-acuity scenarios, justify
culturally sensitive interventions, and evaluate outcomes in dynamic patient situations.
Questions (150 Total)
1.
A 72-year-old male with heart failure (HFrEF, EF 20%) and CKD stage 3 (eGFR 38 mL/min) presents
with acute pulmonary edema: BP 190/102 mm Hg, HR 128 bpm, RR 34/min, SpO₂ 84% on room air,
bilateral crackles to apices. He is prescribed furosemide 80 mg IV, oxygen at 15 L/min via non-rebreather,
and nitroglycerin IV infusion. His potassium is 3.0 mEq/L, and he takes lisinopril and metoprolol at
home.
Which action should the nurse take first?
A. Administer furosemide IV
B. Apply high-flow oxygen and elevate head of bed to 90 degrees
C. Start nitroglycerin infusion
D. Give potassium chloride orally
Rationale (NGN Clinical Judgment Model):
,Recognize Cues: Severe hypoxia (SpO₂ 84%), tachypnea, crackles to apices = acute respiratory
failure.
Analyze Cues: Oxygenation is the immediate life threat; without it, other interventions fail.
Prioritize Hypotheses: Inadequate oxygenation > fluid overload > electrolyte imbalance.
Generate Solutions: Maximize oxygen delivery before diuresis or vasodilation.
Take Action: High Fowler’s (90°) reduces preload; non-rebreather provides up to 90% FiO₂.
Evaluate Outcomes: SpO₂ should rise within 1–2 minutes; work of breathing decreases.
2.
A 3-day-old newborn with ABO incompatibility has a total serum bilirubin of 18 mg/dL. Phototherapy was
initiated 12 hours ago. Current bilirubin is 19.5 mg/dL. The infant is feeding poorly and appears lethargic.
What is the priority intervention?
A. Continue phototherapy and recheck in 4 hours
B. Prepare for exchange transfusion
C. Increase IV fluids
D. Administer IV immunoglobulin (IVIG)
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Rising bilirubin despite phototherapy, poor feeding, lethargy.
Analyze Cues: Bilirubin >19 in a 3-day-old approaches exchange transfusion threshold per AAP
guidelines. Lethargy suggests early kernicterus.
Prioritize Hypotheses: Risk of permanent neurological damage is imminent.
Generate Solutions: Exchange transfusion rapidly removes bilirubin and antibodies.
Take Action: Notify neonatologist, prepare consent, ensure blood products are available.
Evaluate Outcomes: Bilirubin declines; neurological symptoms resolve.
3.
A 58-year-old female with bipolar I disorder is admitted after a manic episode. She is agitated, shouting,
and threatening to leave AMA. She refuses all medications. Her lithium level is 0.2 mEq/L. Security is
called due to escalating behavior.
,What is the nurse’s best action?
A. Restrain her immediately
B. De-escalate verbally, offer PRN lorazepam, and involve psychiatrist for capacity
assessment
C. Administer IM haloperidol without consent
D. Discharge her to avoid conflict
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Mania, agitation, refusal, low lithium, AMA threat.
Analyze Cues: Least restrictive intervention first; restraint is last resort.
Prioritize Hypotheses: Safety and therapeutic engagement > coercion.
Generate Solutions: Verbal de-escalation, offer anxiolytic, assess decisional capacity.
Take Action: “I see you’re upset. Can we talk about what’s bothering you?”
Evaluate Outcomes: Agitation decreases; patient agrees to stay for evaluation.
4.
An 80-year-old Indigenous male with diabetes and dementia is admitted with urosepsis. His family
requests traditional healing practices, including smudging, during care. The unit policy prohibits open
flames.
What should the nurse do?
A. Deny the request due to fire code
B. Collaborate with family and infection control to find a safe alternative (e.g., smokeless
smudge spray)
C. Allow smudging when staff are not present
D. Ignore cultural requests to maintain protocol
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Cultural request, safety policy conflict, vulnerable patient.
Analyze Cues: Cultural humility requires balancing respect with safety.
Prioritize Hypotheses: Patient-centered care includes honoring cultural identity.
, Generate Solutions: Seek compromise—many hospitals now allow smokeless alternatives.
Take Action: Facilitate interdisciplinary discussion with family and risk management.
Evaluate Outcomes: Family feels respected; no safety violations occur.
5.
A 6-year-old with status asthmaticus has SpO₂ 82% on 10 L/min O₂ via mask, RR 52/min, HR 160 bpm,
and silent chest. Continuous albuterol and IV methylprednisolone were started 30 minutes ago.
What is the priority action?
A. Administer another nebulizer treatment
B. Prepare for intubation and mechanical ventilation
C. Obtain ABG
D. Encourage parental presence
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Silent chest = no air movement = respiratory arrest imminent.
Analyze Cues: Exhaustion has set in; medical therapy is failing.
Prioritize Hypotheses: Airway protection is immediately life-saving.
Generate Solutions: Call rapid response, prepare crash cart, notify anesthesia.
Take Action: Ensure equipment (ET tube, laryngoscope) is at bedside.
Evaluate Outcomes: Secured airway; oxygenation restored.
6.
A pregnant client at 34 weeks with preeclampsia (BP 168/102, proteinuria 3+) develops a severe
headache, blurred vision, and RUQ pain. Platelets: 90,000/mm³; AST: 120 U/L.
What complication is developing?
A. Gestational hypertension
B. HELLP syndrome
C. Eclampsia
HESI RN Exit Examination Version 3 (V3) with Next Generation NCLEX® (NGN) Integration | Core
Domains: Advanced Clinical Judgment via NGN Items (Bow-Tie, Extended Multiple Response, Matrix),
Complex Unfolding Case Studies Across the Lifespan, Integrated Pharmacology & Pathophysiology,
Crisis Management & Emergency Response Prioritization, Health Equity & Culturally Competent Care,
Patient Education & Discharge Planning in Evolving Scenarios, and Ethical/Legal Analysis in Dynamic
Clinical Contexts | NCLEX-RN® Readiness Focus | Most Advanced NGN-Enhanced Exit Exam Format
Exam Structure
The HESI Exit Exam V3 with NGN for the 2026/2027 academic cycle is a 150-question, multiple-choice
question (MCQ) and NGN item-type examination.
Introduction
This HESI Exit Exam V3 guide for the 2026/2027 cycle represents the most advanced iteration of the
predictor exam, fully aligned with the Next Generation NCLEX® (NGN) framework. The content
emphasizes high-level clinical judgment through complex, multi-system case studies that require
synthesis of advanced nursing knowledge, sophisticated prioritization, and evidence-based
decision-making under uncertainty for optimal NCLEX-RN® readiness.
Answer Format
All correct answers and advanced clinical judgments must be presented in bold and green, followed by
detailed rationales that meticulously apply the NGN Clinical Judgment Measurement Model, integrate
complex pathophysiology and pharmacology, analyze risk-benefit in high-acuity scenarios, justify
culturally sensitive interventions, and evaluate outcomes in dynamic patient situations.
Questions (150 Total)
1.
A 72-year-old male with heart failure (HFrEF, EF 20%) and CKD stage 3 (eGFR 38 mL/min) presents
with acute pulmonary edema: BP 190/102 mm Hg, HR 128 bpm, RR 34/min, SpO₂ 84% on room air,
bilateral crackles to apices. He is prescribed furosemide 80 mg IV, oxygen at 15 L/min via non-rebreather,
and nitroglycerin IV infusion. His potassium is 3.0 mEq/L, and he takes lisinopril and metoprolol at
home.
Which action should the nurse take first?
A. Administer furosemide IV
B. Apply high-flow oxygen and elevate head of bed to 90 degrees
C. Start nitroglycerin infusion
D. Give potassium chloride orally
Rationale (NGN Clinical Judgment Model):
,Recognize Cues: Severe hypoxia (SpO₂ 84%), tachypnea, crackles to apices = acute respiratory
failure.
Analyze Cues: Oxygenation is the immediate life threat; without it, other interventions fail.
Prioritize Hypotheses: Inadequate oxygenation > fluid overload > electrolyte imbalance.
Generate Solutions: Maximize oxygen delivery before diuresis or vasodilation.
Take Action: High Fowler’s (90°) reduces preload; non-rebreather provides up to 90% FiO₂.
Evaluate Outcomes: SpO₂ should rise within 1–2 minutes; work of breathing decreases.
2.
A 3-day-old newborn with ABO incompatibility has a total serum bilirubin of 18 mg/dL. Phototherapy was
initiated 12 hours ago. Current bilirubin is 19.5 mg/dL. The infant is feeding poorly and appears lethargic.
What is the priority intervention?
A. Continue phototherapy and recheck in 4 hours
B. Prepare for exchange transfusion
C. Increase IV fluids
D. Administer IV immunoglobulin (IVIG)
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Rising bilirubin despite phototherapy, poor feeding, lethargy.
Analyze Cues: Bilirubin >19 in a 3-day-old approaches exchange transfusion threshold per AAP
guidelines. Lethargy suggests early kernicterus.
Prioritize Hypotheses: Risk of permanent neurological damage is imminent.
Generate Solutions: Exchange transfusion rapidly removes bilirubin and antibodies.
Take Action: Notify neonatologist, prepare consent, ensure blood products are available.
Evaluate Outcomes: Bilirubin declines; neurological symptoms resolve.
3.
A 58-year-old female with bipolar I disorder is admitted after a manic episode. She is agitated, shouting,
and threatening to leave AMA. She refuses all medications. Her lithium level is 0.2 mEq/L. Security is
called due to escalating behavior.
,What is the nurse’s best action?
A. Restrain her immediately
B. De-escalate verbally, offer PRN lorazepam, and involve psychiatrist for capacity
assessment
C. Administer IM haloperidol without consent
D. Discharge her to avoid conflict
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Mania, agitation, refusal, low lithium, AMA threat.
Analyze Cues: Least restrictive intervention first; restraint is last resort.
Prioritize Hypotheses: Safety and therapeutic engagement > coercion.
Generate Solutions: Verbal de-escalation, offer anxiolytic, assess decisional capacity.
Take Action: “I see you’re upset. Can we talk about what’s bothering you?”
Evaluate Outcomes: Agitation decreases; patient agrees to stay for evaluation.
4.
An 80-year-old Indigenous male with diabetes and dementia is admitted with urosepsis. His family
requests traditional healing practices, including smudging, during care. The unit policy prohibits open
flames.
What should the nurse do?
A. Deny the request due to fire code
B. Collaborate with family and infection control to find a safe alternative (e.g., smokeless
smudge spray)
C. Allow smudging when staff are not present
D. Ignore cultural requests to maintain protocol
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Cultural request, safety policy conflict, vulnerable patient.
Analyze Cues: Cultural humility requires balancing respect with safety.
Prioritize Hypotheses: Patient-centered care includes honoring cultural identity.
, Generate Solutions: Seek compromise—many hospitals now allow smokeless alternatives.
Take Action: Facilitate interdisciplinary discussion with family and risk management.
Evaluate Outcomes: Family feels respected; no safety violations occur.
5.
A 6-year-old with status asthmaticus has SpO₂ 82% on 10 L/min O₂ via mask, RR 52/min, HR 160 bpm,
and silent chest. Continuous albuterol and IV methylprednisolone were started 30 minutes ago.
What is the priority action?
A. Administer another nebulizer treatment
B. Prepare for intubation and mechanical ventilation
C. Obtain ABG
D. Encourage parental presence
Rationale (NGN Clinical Judgment Model):
Recognize Cues: Silent chest = no air movement = respiratory arrest imminent.
Analyze Cues: Exhaustion has set in; medical therapy is failing.
Prioritize Hypotheses: Airway protection is immediately life-saving.
Generate Solutions: Call rapid response, prepare crash cart, notify anesthesia.
Take Action: Ensure equipment (ET tube, laryngoscope) is at bedside.
Evaluate Outcomes: Secured airway; oxygenation restored.
6.
A pregnant client at 34 weeks with preeclampsia (BP 168/102, proteinuria 3+) develops a severe
headache, blurred vision, and RUQ pain. Platelets: 90,000/mm³; AST: 120 U/L.
What complication is developing?
A. Gestational hypertension
B. HELLP syndrome
C. Eclampsia
