HESI RN EXIT EXAM LATEST 2026 UPDATE 100
QUESTIONS AND DETAILED VERIFIED ANSWERS
FROM ACTUAL EXAMS TEST GRADE A+
Question 1
A nurse is caring for a client with heart failure who reports sudden onset of
dyspnea and coughing up pink, frothy sputum. Which action should the nurse take
first?
A) Administer oxygen via nasal cannula
B) Place the client in high Fowler’s position
C) Notify the healthcare provider
D) Check oxygen saturation
Correct Answer: B
Explanation: High Fowler’s position reduces venous return to the heart and
decreases pulmonary congestion, which is the priority in acute pulmonary edema
to improve breathing. Oxygen administration (A) is important but positioning is
the immediate first action. Notifying the provider (C) and checking SpO2 (D) follow
after positioning and oxygen.
Question 2
A client with type 1 diabetes mellitus has a blood glucose level of 45 mg/dL and is
unconscious. What should the nurse administer first?
A) ½ cup of orange juice
B) 15 g of carbohydrates via nasogastric tube
C) Glucagon 1 mg intramuscularly
D) 50 mL of 50% dextrose IV push
Correct Answer: D
Explanation: For an unconscious hypoglycemic client, IV dextrose is the fastest and
most effective treatment to restore blood glucose. Glucagon (C) is an alternative if
IV access is unavailable but is slower. Oral options (A, B) are unsafe in an
unconscious client due to aspiration risk.
,Question 3
A nurse is assessing a postoperative client for deep vein thrombosis (DVT). Which
finding is most indicative?
A) Bilateral calf swelling
B) Pain in the calf with dorsiflexion of the foot
C) Warm, erythematous area on the lower leg
D) Report of leg fatigue after ambulation
Correct Answer: C
Explanation: Unilateral warmth, erythema, and tenderness are classic signs of
DVT. Bilateral swelling (A) suggests other causes like heart failure. Homan’s sign
(B) is unreliable and no longer recommended. Leg fatigue (D) is nonspecific.
Question 4
A client receiving morphine sulfate for pain has a respiratory rate of 8
breaths/minute. Which medication should the nurse prepare to administer?
A) Naloxone
B) Flumazenil
C) Acetylcysteine
D) Protamine sulfate
Correct Answer: A
Explanation: Naloxone is an opioid antagonist that reverses respiratory depression
caused by morphine. Flumazenil (B) reverses benzodiazepines. Acetylcysteine (C)
treats acetaminophen overdose. Protamine sulfate (D) reverses heparin.
Question 5
The nurse is teaching a client with chronic kidney disease (CKD) about dietary
management. Which statement indicates correct understanding?
A) “I should increase my intake of bananas and oranges.”
B) “I need to limit protein to reduce waste products.”
C) “I will use salt substitutes to lower sodium intake.”
D) “I can eat as much dairy as I want for calcium.”
,Correct Answer: B
Explanation: Protein restriction decreases uremic toxins in CKD. Bananas/oranges
(A) are high in potassium. Salt substitutes (C) often contain potassium chloride,
dangerous in CKD. Dairy (D) is high in phosphorus and potassium.
Question 6
A client with Alzheimer’s disease becomes agitated in the evening. What is the
best nursing intervention?
A) Dim the lights and minimize noise
B) Restrain the client to prevent falls
C) Administer a PRN sedative immediately
D) Encourage the client to take a warm bath
Correct Answer: A
Explanation: A calm, quiet environment reduces sundowning agitation in
Alzheimer’s. Restraints (B) increase agitation and injury risk. Sedatives (C) are last-
line due to side effects. Warm bath (D) may overstimulate.
Question 7
A nurse is caring for a client with a chest tube following a pneumothorax. Which
finding requires immediate intervention?
A) Continuous bubbling in the water seal chamber
B) Tidaling in the water seal chamber
C) Serosanguinous drainage of 50 mL in 4 hours
D) Crepitus at the insertion site
Correct Answer: A
Explanation: Continuous bubbling indicates an air leak, which requires immediate
investigation. Tidaling (B) is normal. Moderate drainage (C) is expected. Crepitus
(D) is common after chest tube placement and not urgent.
Question 8
A postpartum client with Rh-negative blood gives birth to an Rh-positive infant.
Which medication should the nurse administer?
A) Rho(D) immune globulin
, B) Methylergonovine
C) Hepatitis B vaccine
D) Rh immunoglobulin only if antibody screen is positive
Correct Answer: A
*Explanation: Rho(D) immune globulin is given to Rh-negative mothers within 72
hours of delivery of an Rh-positive infant to prevent sensitization.
Methylergonovine (B) treats hemorrhage. Hepatitis B vaccine (C) is for the infant.
It is given regardless of antibody screen (D) being negative.*
Question 9
A client on a mechanical ventilator has an endotracheal tube. Which nursing
action is most important to prevent ventilator-associated pneumonia (VAP)?
A) Suction the tube every hour
B) Elevate the head of the bed to 30-45 degrees
C) Change the ventilator circuit daily
D) Instill normal saline before suctioning
Correct Answer: B
*Explanation: Semi-recumbent positioning (30-45°) reduces aspiration risk, a key
VAP prevention strategy. Frequent suctioning (A) can cause trauma. Daily circuit
changes (C) are not recommended. Saline instillation (D) is no longer standard.*
Question 10
The nurse assesses a client with major depressive disorder who says, “I don’t have
a reason to live anymore.” What is the priority nursing action?
A) Ask, “Do you have a plan to harm yourself?”
B) Tell the client “You have so much to live for.”
C) Leave the client alone to calm down
D) Notify the healthcare provider immediately
Correct Answer: A
Explanation: Directly assessing suicidal ideation, including plan and means, is the
priority for safety. Minimizing feelings (B) is nontherapeutic; leaving alone (C) risks
self-harm; notifying provider (D) follows but does not replace direct assessment.
QUESTIONS AND DETAILED VERIFIED ANSWERS
FROM ACTUAL EXAMS TEST GRADE A+
Question 1
A nurse is caring for a client with heart failure who reports sudden onset of
dyspnea and coughing up pink, frothy sputum. Which action should the nurse take
first?
A) Administer oxygen via nasal cannula
B) Place the client in high Fowler’s position
C) Notify the healthcare provider
D) Check oxygen saturation
Correct Answer: B
Explanation: High Fowler’s position reduces venous return to the heart and
decreases pulmonary congestion, which is the priority in acute pulmonary edema
to improve breathing. Oxygen administration (A) is important but positioning is
the immediate first action. Notifying the provider (C) and checking SpO2 (D) follow
after positioning and oxygen.
Question 2
A client with type 1 diabetes mellitus has a blood glucose level of 45 mg/dL and is
unconscious. What should the nurse administer first?
A) ½ cup of orange juice
B) 15 g of carbohydrates via nasogastric tube
C) Glucagon 1 mg intramuscularly
D) 50 mL of 50% dextrose IV push
Correct Answer: D
Explanation: For an unconscious hypoglycemic client, IV dextrose is the fastest and
most effective treatment to restore blood glucose. Glucagon (C) is an alternative if
IV access is unavailable but is slower. Oral options (A, B) are unsafe in an
unconscious client due to aspiration risk.
,Question 3
A nurse is assessing a postoperative client for deep vein thrombosis (DVT). Which
finding is most indicative?
A) Bilateral calf swelling
B) Pain in the calf with dorsiflexion of the foot
C) Warm, erythematous area on the lower leg
D) Report of leg fatigue after ambulation
Correct Answer: C
Explanation: Unilateral warmth, erythema, and tenderness are classic signs of
DVT. Bilateral swelling (A) suggests other causes like heart failure. Homan’s sign
(B) is unreliable and no longer recommended. Leg fatigue (D) is nonspecific.
Question 4
A client receiving morphine sulfate for pain has a respiratory rate of 8
breaths/minute. Which medication should the nurse prepare to administer?
A) Naloxone
B) Flumazenil
C) Acetylcysteine
D) Protamine sulfate
Correct Answer: A
Explanation: Naloxone is an opioid antagonist that reverses respiratory depression
caused by morphine. Flumazenil (B) reverses benzodiazepines. Acetylcysteine (C)
treats acetaminophen overdose. Protamine sulfate (D) reverses heparin.
Question 5
The nurse is teaching a client with chronic kidney disease (CKD) about dietary
management. Which statement indicates correct understanding?
A) “I should increase my intake of bananas and oranges.”
B) “I need to limit protein to reduce waste products.”
C) “I will use salt substitutes to lower sodium intake.”
D) “I can eat as much dairy as I want for calcium.”
,Correct Answer: B
Explanation: Protein restriction decreases uremic toxins in CKD. Bananas/oranges
(A) are high in potassium. Salt substitutes (C) often contain potassium chloride,
dangerous in CKD. Dairy (D) is high in phosphorus and potassium.
Question 6
A client with Alzheimer’s disease becomes agitated in the evening. What is the
best nursing intervention?
A) Dim the lights and minimize noise
B) Restrain the client to prevent falls
C) Administer a PRN sedative immediately
D) Encourage the client to take a warm bath
Correct Answer: A
Explanation: A calm, quiet environment reduces sundowning agitation in
Alzheimer’s. Restraints (B) increase agitation and injury risk. Sedatives (C) are last-
line due to side effects. Warm bath (D) may overstimulate.
Question 7
A nurse is caring for a client with a chest tube following a pneumothorax. Which
finding requires immediate intervention?
A) Continuous bubbling in the water seal chamber
B) Tidaling in the water seal chamber
C) Serosanguinous drainage of 50 mL in 4 hours
D) Crepitus at the insertion site
Correct Answer: A
Explanation: Continuous bubbling indicates an air leak, which requires immediate
investigation. Tidaling (B) is normal. Moderate drainage (C) is expected. Crepitus
(D) is common after chest tube placement and not urgent.
Question 8
A postpartum client with Rh-negative blood gives birth to an Rh-positive infant.
Which medication should the nurse administer?
A) Rho(D) immune globulin
, B) Methylergonovine
C) Hepatitis B vaccine
D) Rh immunoglobulin only if antibody screen is positive
Correct Answer: A
*Explanation: Rho(D) immune globulin is given to Rh-negative mothers within 72
hours of delivery of an Rh-positive infant to prevent sensitization.
Methylergonovine (B) treats hemorrhage. Hepatitis B vaccine (C) is for the infant.
It is given regardless of antibody screen (D) being negative.*
Question 9
A client on a mechanical ventilator has an endotracheal tube. Which nursing
action is most important to prevent ventilator-associated pneumonia (VAP)?
A) Suction the tube every hour
B) Elevate the head of the bed to 30-45 degrees
C) Change the ventilator circuit daily
D) Instill normal saline before suctioning
Correct Answer: B
*Explanation: Semi-recumbent positioning (30-45°) reduces aspiration risk, a key
VAP prevention strategy. Frequent suctioning (A) can cause trauma. Daily circuit
changes (C) are not recommended. Saline instillation (D) is no longer standard.*
Question 10
The nurse assesses a client with major depressive disorder who says, “I don’t have
a reason to live anymore.” What is the priority nursing action?
A) Ask, “Do you have a plan to harm yourself?”
B) Tell the client “You have so much to live for.”
C) Leave the client alone to calm down
D) Notify the healthcare provider immediately
Correct Answer: A
Explanation: Directly assessing suicidal ideation, including plan and means, is the
priority for safety. Minimizing feelings (B) is nontherapeutic; leaving alone (C) risks
self-harm; notifying provider (D) follows but does not replace direct assessment.
