HESI RN EXIT EXAM VERSION 2 - NGN + RATIONALES – EXAM-STYLE
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS | PLUS
RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST
1. A nurse is preparing to administer a scheduled dose of digoxin to a client
with heart failure. The client's apical pulse is 54 beats per minute and irregular.
Which action should the nurse take first?
A. Administer the digoxin as ordered.
B. Hold the medication and reassess the pulse in 30 minutes.
C. Notify the healthcare provider immediately.
D. Check the client's serum digoxin level.
Correct Answer: B. Hold the medication and reassess the pulse in 30 minutes.
*Rationale: The standard protocol for digoxin administration is to hold the dose if
the apical pulse is less than 60 beats per minute (or less than 70 in pediatric clients)
and reassess in 30 minutes. While a rate of 54 with an irregular rhythm warrants
caution, it is not an immediate emergency requiring a call to the provider as the
first step. The nurse's primary action is to verify the pulse again after a short
interval to confirm the finding before holding or notifying, which is the safest and
most appropriate initial nursing action. Administering it (A) would be unsafe. While
checking the digoxin level (D) is important, it is not the immediate first step in this
scenario.
,2. A client who is 2 days post-operative following a total knee arthroplasty
reports sudden onset of shortness of breath and pleuritic chest pain. The nurse
notes the client is tachycardic and hypoxic. Which complication should the
nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Fat embolism syndrome
D. Pneumonia
Correct Answer: B. Pulmonary embolism
*Rationale: The sudden onset of shortness of breath, pleuritic chest pain,
tachycardia, and hypoxia in a post-operative client who has been immobile is
highly indicative of a pulmonary embolism (PE). This is a medical emergency.
Atelectasis (A) typically presents more gradually with fever and crackles. Fat
embolism syndrome (C) often presents with petechiae, confusion, and respiratory
distress, but its onset is usually 12-72 hours post-fracture, and the classic triad
includes a petechial rash. Pneumonia (D) would typically develop more gradually
and be accompanied by a productive cough and fever. The acute nature of these
symptoms points directly to a PE.
3. The healthcare provider orders 1000 mL of 0.9% Normal Saline to infuse over
8 hours. The drop factor of the IV tubing is 15 gtt/mL. What is the initial drip
rate the nurse should set to infuse this solution at the correct rate? (Round to
the nearest whole number.)
,A. 31 gtt/min
B. 33 gtt/min
C. 125 gtt/min
D. 100 gtt/min
Correct Answer: A. 31 gtt/min
*Rationale: To calculate the drip rate, use the formula: (Volume in mL / Time in
minutes) x Drop factor = gtt/min. (1000 mL / 480 min) x 15 gtt/mL = 31.25
gtt/min. Rounded to the nearest whole number, the rate is 31 gtt/min. Option B
(33) would result from a mathematical error. Option C (125) is the hourly rate, not
the drip rate. Option D (100) is incorrect and not supported by the calculation.
4. A nurse is providing discharge teaching to a client with a new diagnosis of
Type 1 diabetes. Which statement by the client indicates a need for further
teaching?
A. "I will rotate my insulin injection sites to prevent lipodystrophy."
B. "I will carry a source of fast-acting glucose with me at all times."
C. "I should take my regular insulin 30 minutes before I eat my meals."
D. "I can skip my insulin dose if I am not planning to eat a full meal."
Correct Answer: D. "I can skip my insulin dose if I am not planning to eat a full
meal."
*Rationale: Skipping insulin is dangerous and indicates a critical misunderstanding
of the disease process. Clients with Type 1 diabetes require exogenous insulin at all
times to prevent diabetic ketoacidosis (DKA). The other statements are correct:
, rotation of sites prevents lipodystrophy (A), carrying a fast-acting glucose source is
essential for treating hypoglycemia (B), and regular insulin is often taken 30
minutes before meals (C).
5. A client is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the infusion starts, the client reports chills and low back pain.
What is the nurse's priority action?
A. Slow the transfusion rate and monitor the client closely.
B. Administer diphenhydramine as a pre-medication.
C. Stop the transfusion and disconnect the IV tubing.
D. Stop the transfusion, keep the IV line open with normal saline, and notify the
blood bank.
Correct Answer: D. Stop the transfusion, keep the IV line open with normal
saline, and notify the blood bank.
*Rationale: The client's symptoms are consistent with a possible acute hemolytic
transfusion reaction. The immediate priority is to stop the transfusion to prevent
further exposure, keep the IV line patent with normal saline (separate tubing from
the blood product) to maintain vascular access, and notify the blood bank and
healthcare provider. Option C is incorrect because the IV line should remain open.
Option A would be dangerous as it delays stopping the reaction. Option B is an
intervention for a mild allergic reaction, not a potentially life-threatening hemolytic
one.
QUESTIONS AND ANSWERS | VERIFIED AND WELL DETAILED ANSWERS | PLUS
RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST
1. A nurse is preparing to administer a scheduled dose of digoxin to a client
with heart failure. The client's apical pulse is 54 beats per minute and irregular.
Which action should the nurse take first?
A. Administer the digoxin as ordered.
B. Hold the medication and reassess the pulse in 30 minutes.
C. Notify the healthcare provider immediately.
D. Check the client's serum digoxin level.
Correct Answer: B. Hold the medication and reassess the pulse in 30 minutes.
*Rationale: The standard protocol for digoxin administration is to hold the dose if
the apical pulse is less than 60 beats per minute (or less than 70 in pediatric clients)
and reassess in 30 minutes. While a rate of 54 with an irregular rhythm warrants
caution, it is not an immediate emergency requiring a call to the provider as the
first step. The nurse's primary action is to verify the pulse again after a short
interval to confirm the finding before holding or notifying, which is the safest and
most appropriate initial nursing action. Administering it (A) would be unsafe. While
checking the digoxin level (D) is important, it is not the immediate first step in this
scenario.
,2. A client who is 2 days post-operative following a total knee arthroplasty
reports sudden onset of shortness of breath and pleuritic chest pain. The nurse
notes the client is tachycardic and hypoxic. Which complication should the
nurse suspect first?
A. Atelectasis
B. Pulmonary embolism
C. Fat embolism syndrome
D. Pneumonia
Correct Answer: B. Pulmonary embolism
*Rationale: The sudden onset of shortness of breath, pleuritic chest pain,
tachycardia, and hypoxia in a post-operative client who has been immobile is
highly indicative of a pulmonary embolism (PE). This is a medical emergency.
Atelectasis (A) typically presents more gradually with fever and crackles. Fat
embolism syndrome (C) often presents with petechiae, confusion, and respiratory
distress, but its onset is usually 12-72 hours post-fracture, and the classic triad
includes a petechial rash. Pneumonia (D) would typically develop more gradually
and be accompanied by a productive cough and fever. The acute nature of these
symptoms points directly to a PE.
3. The healthcare provider orders 1000 mL of 0.9% Normal Saline to infuse over
8 hours. The drop factor of the IV tubing is 15 gtt/mL. What is the initial drip
rate the nurse should set to infuse this solution at the correct rate? (Round to
the nearest whole number.)
,A. 31 gtt/min
B. 33 gtt/min
C. 125 gtt/min
D. 100 gtt/min
Correct Answer: A. 31 gtt/min
*Rationale: To calculate the drip rate, use the formula: (Volume in mL / Time in
minutes) x Drop factor = gtt/min. (1000 mL / 480 min) x 15 gtt/mL = 31.25
gtt/min. Rounded to the nearest whole number, the rate is 31 gtt/min. Option B
(33) would result from a mathematical error. Option C (125) is the hourly rate, not
the drip rate. Option D (100) is incorrect and not supported by the calculation.
4. A nurse is providing discharge teaching to a client with a new diagnosis of
Type 1 diabetes. Which statement by the client indicates a need for further
teaching?
A. "I will rotate my insulin injection sites to prevent lipodystrophy."
B. "I will carry a source of fast-acting glucose with me at all times."
C. "I should take my regular insulin 30 minutes before I eat my meals."
D. "I can skip my insulin dose if I am not planning to eat a full meal."
Correct Answer: D. "I can skip my insulin dose if I am not planning to eat a full
meal."
*Rationale: Skipping insulin is dangerous and indicates a critical misunderstanding
of the disease process. Clients with Type 1 diabetes require exogenous insulin at all
times to prevent diabetic ketoacidosis (DKA). The other statements are correct:
, rotation of sites prevents lipodystrophy (A), carrying a fast-acting glucose source is
essential for treating hypoglycemia (B), and regular insulin is often taken 30
minutes before meals (C).
5. A client is receiving a blood transfusion of packed red blood cells. Fifteen
minutes after the infusion starts, the client reports chills and low back pain.
What is the nurse's priority action?
A. Slow the transfusion rate and monitor the client closely.
B. Administer diphenhydramine as a pre-medication.
C. Stop the transfusion and disconnect the IV tubing.
D. Stop the transfusion, keep the IV line open with normal saline, and notify the
blood bank.
Correct Answer: D. Stop the transfusion, keep the IV line open with normal
saline, and notify the blood bank.
*Rationale: The client's symptoms are consistent with a possible acute hemolytic
transfusion reaction. The immediate priority is to stop the transfusion to prevent
further exposure, keep the IV line patent with normal saline (separate tubing from
the blood product) to maintain vascular access, and notify the blood bank and
healthcare provider. Option C is incorrect because the IV line should remain open.
Option A would be dangerous as it delays stopping the reaction. Option B is an
intervention for a mild allergic reaction, not a potentially life-threatening hemolytic
one.
