RN Exit Exam Practice Test Bank — Full Rationale Edition (2026)
160 Original Questions · Correct Answer · Why It’s Right · Why Each Distractor Is Wrong · Reference
About this document: These are original practice questions written to mirror the content blueprint and difficulty of a nursing exit exam (Med-
Surg, Pharmacology, Maternal-Newborn, Pediatrics, Mental Health, Leadership, Fundamentals, and NGN case studies). They are not reproductions of
Elsevier/HESI’s copyrighted exam bank — I don’t have access to that proprietary content, and nothing here should be read as “leaked” or officially
verified HESI material.
On “References”: Each question lists a standard nursing textbook covering that content area, so you can read further and cross-check the
underlying concept. These point to the topic, not to a literal source of the question (since the question itself is original), and I’m not quoting or
reproducing text from these books.
SECTION 1: MEDICAL-SURGICAL NURSING (Q1–Q40)
Reference for this section: Lewis et al., Medical-Surgical Nursing: Assessment and Management of Clinical Problems
1. A client with COPD has ABGs: pH 7.32, PaCO2 58, HCO3 30. This indicates:
A) Respiratory alkalosis B) Metabolic acidosis C) Compensated respiratory acidosis D) Uncompensated metabolic alkalosis
Answer: C. Low pH + high CO2 = respiratory acidosis; the elevated HCO3 shows the kidneys are compensating, typical in chronic
COPD.
Why not the others: A is wrong — pH is low, not high, ruling out alkalosis. B is wrong — the primary problem is a high PaCO2
(respiratory), not a low HCO3 (metabolic). D is wrong — pH is acidic, not alkalotic, and this isn’t an uncompensated picture since
HCO3 has already risen.
2. Priority assessment for a client 2 hours post-thyroidectomy?
A) Blood glucose B) Voice hoarseness C) Airway/neck for swelling D) Bowel sounds
Answer: C. Hematoma formation can compress the airway rapidly after thyroidectomy — the top priority complication.
Why not the others: A is a lower priority; glucose isn’t the expected surgical complication here. B is a valid concern (recurrent
laryngeal nerve injury) but is not immediately life-threatening like airway obstruction. D is a routine post-op check, not the priority
in the first hours.
3. Which lab value best indicates a client with heart failure is responding to diuretic therapy?
A) Decreased BNP B) Increased potassium C) Increased creatinine D) Decreased hemoglobin
Answer: A. Falling BNP reflects reduced ventricular wall stress from decreasing fluid overload.
Why not the others: B — rising potassium isn’t a marker of diuretic success and can actually be an adverse effect of some
diuretics. C — rising creatinine suggests worsening renal function/over-diuresis, a concerning finding, not improvement. D —
hemoglobin isn’t a standard marker of diuretic response.
4. Early sign of compartment syndrome?
A) Absent pulse B) Pain unrelieved by opioids C) Paralysis D) Cyanosis
Answer: B. Pain out of proportion to injury, unrelieved by analgesics, is the earliest and most reliable sign.
Why not the others: A, C, and D (the “5 P’s” beyond pain) are late findings that occur after significant tissue ischemia has already
developed — waiting for these delays treatment.
5. A client with a chest tube has continuous bubbling in the water seal chamber. This indicates:
A) Normal functioning B) An air leak C) Resolved pneumothorax D) Suction is too high
Answer: B. Continuous (not intermittent) bubbling in the water seal chamber signals air entering the system from a leak.
Why not the others: A is incorrect — intermittent bubbling during exhalation/coughing is normal, not continuous bubbling. C is
wrong — a resolved pneumothorax would show no bubbling at all. D describes vigorous bubbling in the suction control chamber, a
different finding.
,6. Which finding requires immediate intervention in a client with a new AV fistula?
A) Thrill palpable B) Bruit auscultated C) Absent thrill D) Warmth over site
Answer: C. Absent thrill suggests clotting/occlusion of the fistula — a vascular access emergency.
Why not the others: A and B are expected, reassuring findings that confirm blood flow through the fistula. D is a normal finding
from increased blood flow, not a red flag.
7. Best position for a client with increased intracranial pressure?
A) Trendelenburg B) Supine flat C) Head of bed elevated 30° D) Prone
Answer: C. Elevating the head of bed ~30° promotes venous drainage from the brain and helps lower ICP.
Why not the others: A (Trendelenburg) increases venous congestion in the head and raises ICP. B (flat) does not optimize venous
outflow. D (prone) is not used and can further increase intra-abdominal/intrathoracic pressure, raising ICP.
8. A client on warfarin has an INR of 6.0 with no bleeding. Priority nursing action?
A) Administer next dose as scheduled B) Hold warfarin and notify provider C) Give protamine sulfate D) Increase dietary vitamin K
only
Answer: B. An INR of 6.0 is critically supratherapeutic; the dose should be held and the provider notified for further orders (often
oral vitamin K).
Why not the others: A would worsen an already dangerous bleeding risk. C is the antidote for heparin, not warfarin, and is not a
nursing-initiated action. D — vitamin K may be given, but as a provider-directed treatment, not a unilateral dietary fix the nurse
initiates alone.
9. Which stoma appearance requires immediate provider notification?
A) Pink/red and moist B) Slight edema in first 24 hrs C) Dusky or purple-black D) Mild bleeding on touch
Answer: C. A dusky or purple-black stoma indicates ischemia/necrosis and needs urgent evaluation.
Why not the others: A is the expected, healthy appearance. B is a normal, temporary post-op finding. D — minor bleeding from
light contact is common and expected due to the stoma’s rich vascularity.
10. Client with SIADH — expected finding?
A) Hypernatremia and polyuria B) Hyponatremia and concentrated urine C) Hypokalemia and dilute urine D) Hypernatremia and
edema
Answer: B. SIADH causes water retention, which dilutes serum sodium (hyponatremia) while urine becomes concentrated.
Why not the others: A and D describe hypernatremia/dehydration patterns — the opposite of SIADH’s water-retentive physiology.
C describes potassium and dilute urine, not the classic SIADH sodium/urine pattern.
11. Priority action for a client experiencing a sickle cell crisis?
A) Apply ice packs B) Administer IV fluids and analgesia C) Restrict fluids D) Encourage ambulation
Answer: B. Hydration reduces blood viscosity/sickling, and pain control addresses the severe vaso-occlusive pain.
Why not the others: A — cold promotes vasoconstriction, worsening sickling; warmth is preferred. C — fluids should be increased,
not restricted, to reduce viscosity. D — during an acute crisis, rest is prioritized over activity.
12. Which client is at greatest risk for refeeding syndrome?
A) Client with obesity B) Severely malnourished client starting enteral feeds C) Client with type 2 diabetes D) Client post-
appendectomy
Answer: B. Reintroducing nutrition after prolonged malnutrition causes a rapid insulin-driven shift of phosphate, potassium, and
magnesium into cells.
Why not the others: A, C, and D don’t carry the prolonged catabolic starvation state that triggers the syndrome.
, 13. A client with cirrhosis develops asterixis. This suggests:
A) Hypoglycemia B) Hepatic encephalopathy C) Esophageal varices bleed D) Ascites worsening
Answer: B. Asterixis (“liver flap”) reflects rising ammonia levels affecting the CNS — a hallmark of hepatic encephalopathy.
Why not the others: A, C, and D are all real cirrhosis complications, but none of them present with this specific neuromuscular
sign.
14. Best indicator of adequate tissue perfusion post-abdominal aortic aneurysm repair?
A) Blood pressure alone B) Pedal pulses and capillary refill C) Urine color D) Bowel sounds
Answer: B. Direct assessment of distal circulation (pulses, cap refill, warmth, color) evaluates perfusion to the legs after aortic
surgery.
Why not the others: A — BP alone doesn’t confirm adequate flow to the extremities distal to the repair. C and D assess other
systems (renal, GI), not limb perfusion specifically.
15. Client with myasthenia gravis — priority concern?
A) Joint pain B) Respiratory muscle weakness C) Skin breakdown D) Constipation
Answer: B. Myasthenic crisis with respiratory muscle failure is the life-threatening priority in this disease.
Why not the others: A, C, and D are not the hallmark or most dangerous features of myasthenia gravis.
16. Expected finding in a client with Addisonian crisis?
A) Hypertension and hypernatremia B) Hypotension, hyponatremia, hyperkalemia C) Hypertension and hypokalemia D) Fluid
overload
Answer: B. Loss of cortisol/aldosterone causes sodium and water loss (hypotension, hyponatremia) and potassium retention
(hyperkalemia).
Why not the others: A, C, and D all describe hypertensive/fluid-excess states, which is the opposite of the profound hypotension
and volume depletion seen in adrenal crisis.
17. Client with a new colostomy asks when stool will return to normal consistency. Best response addresses:
A) Immediately after surgery B) It depends on stoma location — more liquid the higher in the colon C) Never changes D) Only
ileostomies change consistency
Answer: B. Output consistency correlates with how much of the colon remains to reabsorb water — ascending colostomies are
looser, descending/sigmoid are more formed.
Why not the others: A is inaccurate — output is typically liquid initially regardless of location. C is false; consistency does change
over time and with diet. D ignores that colostomy output also varies by location.
18. Priority nursing action for suspected transfusion reaction?
A) Slow the infusion B) Stop the transfusion and infuse NS via new tubing C) Administer antihistamine and continue D) Document
and reassess in 30 min
Answer: B. The transfusion must be stopped immediately; new tubing with normal saline keeps the vein open while the reaction is
managed.
Why not the others: A — slowing (not stopping) still exposes the client to more of the reactive blood product. C — medicating
without stopping the transfusion risks masking a worsening reaction. D delays action during a potentially life-threatening event.
19. Client with DKA — priority initial intervention?
A) Administer insulin bolus B) IV fluid resuscitation C) Correct potassium first D) Administer bicarbonate
Answer: B. Fluids are given first to restore intravascular volume and perfusion before starting insulin, which can worsen
hypotension by shifting fluid intracellularly.
Why not the others: A — insulin before adequate fluid resuscitation risks cardiovascular collapse. C — potassium must actually be
verified as adequate before insulin is started (insulin drives K into cells), not corrected first in isolation. D — bicarbonate isn’t
routine DKA therapy.
160 Original Questions · Correct Answer · Why It’s Right · Why Each Distractor Is Wrong · Reference
About this document: These are original practice questions written to mirror the content blueprint and difficulty of a nursing exit exam (Med-
Surg, Pharmacology, Maternal-Newborn, Pediatrics, Mental Health, Leadership, Fundamentals, and NGN case studies). They are not reproductions of
Elsevier/HESI’s copyrighted exam bank — I don’t have access to that proprietary content, and nothing here should be read as “leaked” or officially
verified HESI material.
On “References”: Each question lists a standard nursing textbook covering that content area, so you can read further and cross-check the
underlying concept. These point to the topic, not to a literal source of the question (since the question itself is original), and I’m not quoting or
reproducing text from these books.
SECTION 1: MEDICAL-SURGICAL NURSING (Q1–Q40)
Reference for this section: Lewis et al., Medical-Surgical Nursing: Assessment and Management of Clinical Problems
1. A client with COPD has ABGs: pH 7.32, PaCO2 58, HCO3 30. This indicates:
A) Respiratory alkalosis B) Metabolic acidosis C) Compensated respiratory acidosis D) Uncompensated metabolic alkalosis
Answer: C. Low pH + high CO2 = respiratory acidosis; the elevated HCO3 shows the kidneys are compensating, typical in chronic
COPD.
Why not the others: A is wrong — pH is low, not high, ruling out alkalosis. B is wrong — the primary problem is a high PaCO2
(respiratory), not a low HCO3 (metabolic). D is wrong — pH is acidic, not alkalotic, and this isn’t an uncompensated picture since
HCO3 has already risen.
2. Priority assessment for a client 2 hours post-thyroidectomy?
A) Blood glucose B) Voice hoarseness C) Airway/neck for swelling D) Bowel sounds
Answer: C. Hematoma formation can compress the airway rapidly after thyroidectomy — the top priority complication.
Why not the others: A is a lower priority; glucose isn’t the expected surgical complication here. B is a valid concern (recurrent
laryngeal nerve injury) but is not immediately life-threatening like airway obstruction. D is a routine post-op check, not the priority
in the first hours.
3. Which lab value best indicates a client with heart failure is responding to diuretic therapy?
A) Decreased BNP B) Increased potassium C) Increased creatinine D) Decreased hemoglobin
Answer: A. Falling BNP reflects reduced ventricular wall stress from decreasing fluid overload.
Why not the others: B — rising potassium isn’t a marker of diuretic success and can actually be an adverse effect of some
diuretics. C — rising creatinine suggests worsening renal function/over-diuresis, a concerning finding, not improvement. D —
hemoglobin isn’t a standard marker of diuretic response.
4. Early sign of compartment syndrome?
A) Absent pulse B) Pain unrelieved by opioids C) Paralysis D) Cyanosis
Answer: B. Pain out of proportion to injury, unrelieved by analgesics, is the earliest and most reliable sign.
Why not the others: A, C, and D (the “5 P’s” beyond pain) are late findings that occur after significant tissue ischemia has already
developed — waiting for these delays treatment.
5. A client with a chest tube has continuous bubbling in the water seal chamber. This indicates:
A) Normal functioning B) An air leak C) Resolved pneumothorax D) Suction is too high
Answer: B. Continuous (not intermittent) bubbling in the water seal chamber signals air entering the system from a leak.
Why not the others: A is incorrect — intermittent bubbling during exhalation/coughing is normal, not continuous bubbling. C is
wrong — a resolved pneumothorax would show no bubbling at all. D describes vigorous bubbling in the suction control chamber, a
different finding.
,6. Which finding requires immediate intervention in a client with a new AV fistula?
A) Thrill palpable B) Bruit auscultated C) Absent thrill D) Warmth over site
Answer: C. Absent thrill suggests clotting/occlusion of the fistula — a vascular access emergency.
Why not the others: A and B are expected, reassuring findings that confirm blood flow through the fistula. D is a normal finding
from increased blood flow, not a red flag.
7. Best position for a client with increased intracranial pressure?
A) Trendelenburg B) Supine flat C) Head of bed elevated 30° D) Prone
Answer: C. Elevating the head of bed ~30° promotes venous drainage from the brain and helps lower ICP.
Why not the others: A (Trendelenburg) increases venous congestion in the head and raises ICP. B (flat) does not optimize venous
outflow. D (prone) is not used and can further increase intra-abdominal/intrathoracic pressure, raising ICP.
8. A client on warfarin has an INR of 6.0 with no bleeding. Priority nursing action?
A) Administer next dose as scheduled B) Hold warfarin and notify provider C) Give protamine sulfate D) Increase dietary vitamin K
only
Answer: B. An INR of 6.0 is critically supratherapeutic; the dose should be held and the provider notified for further orders (often
oral vitamin K).
Why not the others: A would worsen an already dangerous bleeding risk. C is the antidote for heparin, not warfarin, and is not a
nursing-initiated action. D — vitamin K may be given, but as a provider-directed treatment, not a unilateral dietary fix the nurse
initiates alone.
9. Which stoma appearance requires immediate provider notification?
A) Pink/red and moist B) Slight edema in first 24 hrs C) Dusky or purple-black D) Mild bleeding on touch
Answer: C. A dusky or purple-black stoma indicates ischemia/necrosis and needs urgent evaluation.
Why not the others: A is the expected, healthy appearance. B is a normal, temporary post-op finding. D — minor bleeding from
light contact is common and expected due to the stoma’s rich vascularity.
10. Client with SIADH — expected finding?
A) Hypernatremia and polyuria B) Hyponatremia and concentrated urine C) Hypokalemia and dilute urine D) Hypernatremia and
edema
Answer: B. SIADH causes water retention, which dilutes serum sodium (hyponatremia) while urine becomes concentrated.
Why not the others: A and D describe hypernatremia/dehydration patterns — the opposite of SIADH’s water-retentive physiology.
C describes potassium and dilute urine, not the classic SIADH sodium/urine pattern.
11. Priority action for a client experiencing a sickle cell crisis?
A) Apply ice packs B) Administer IV fluids and analgesia C) Restrict fluids D) Encourage ambulation
Answer: B. Hydration reduces blood viscosity/sickling, and pain control addresses the severe vaso-occlusive pain.
Why not the others: A — cold promotes vasoconstriction, worsening sickling; warmth is preferred. C — fluids should be increased,
not restricted, to reduce viscosity. D — during an acute crisis, rest is prioritized over activity.
12. Which client is at greatest risk for refeeding syndrome?
A) Client with obesity B) Severely malnourished client starting enteral feeds C) Client with type 2 diabetes D) Client post-
appendectomy
Answer: B. Reintroducing nutrition after prolonged malnutrition causes a rapid insulin-driven shift of phosphate, potassium, and
magnesium into cells.
Why not the others: A, C, and D don’t carry the prolonged catabolic starvation state that triggers the syndrome.
, 13. A client with cirrhosis develops asterixis. This suggests:
A) Hypoglycemia B) Hepatic encephalopathy C) Esophageal varices bleed D) Ascites worsening
Answer: B. Asterixis (“liver flap”) reflects rising ammonia levels affecting the CNS — a hallmark of hepatic encephalopathy.
Why not the others: A, C, and D are all real cirrhosis complications, but none of them present with this specific neuromuscular
sign.
14. Best indicator of adequate tissue perfusion post-abdominal aortic aneurysm repair?
A) Blood pressure alone B) Pedal pulses and capillary refill C) Urine color D) Bowel sounds
Answer: B. Direct assessment of distal circulation (pulses, cap refill, warmth, color) evaluates perfusion to the legs after aortic
surgery.
Why not the others: A — BP alone doesn’t confirm adequate flow to the extremities distal to the repair. C and D assess other
systems (renal, GI), not limb perfusion specifically.
15. Client with myasthenia gravis — priority concern?
A) Joint pain B) Respiratory muscle weakness C) Skin breakdown D) Constipation
Answer: B. Myasthenic crisis with respiratory muscle failure is the life-threatening priority in this disease.
Why not the others: A, C, and D are not the hallmark or most dangerous features of myasthenia gravis.
16. Expected finding in a client with Addisonian crisis?
A) Hypertension and hypernatremia B) Hypotension, hyponatremia, hyperkalemia C) Hypertension and hypokalemia D) Fluid
overload
Answer: B. Loss of cortisol/aldosterone causes sodium and water loss (hypotension, hyponatremia) and potassium retention
(hyperkalemia).
Why not the others: A, C, and D all describe hypertensive/fluid-excess states, which is the opposite of the profound hypotension
and volume depletion seen in adrenal crisis.
17. Client with a new colostomy asks when stool will return to normal consistency. Best response addresses:
A) Immediately after surgery B) It depends on stoma location — more liquid the higher in the colon C) Never changes D) Only
ileostomies change consistency
Answer: B. Output consistency correlates with how much of the colon remains to reabsorb water — ascending colostomies are
looser, descending/sigmoid are more formed.
Why not the others: A is inaccurate — output is typically liquid initially regardless of location. C is false; consistency does change
over time and with diet. D ignores that colostomy output also varies by location.
18. Priority nursing action for suspected transfusion reaction?
A) Slow the infusion B) Stop the transfusion and infuse NS via new tubing C) Administer antihistamine and continue D) Document
and reassess in 30 min
Answer: B. The transfusion must be stopped immediately; new tubing with normal saline keeps the vein open while the reaction is
managed.
Why not the others: A — slowing (not stopping) still exposes the client to more of the reactive blood product. C — medicating
without stopping the transfusion risks masking a worsening reaction. D delays action during a potentially life-threatening event.
19. Client with DKA — priority initial intervention?
A) Administer insulin bolus B) IV fluid resuscitation C) Correct potassium first D) Administer bicarbonate
Answer: B. Fluids are given first to restore intravascular volume and perfusion before starting insulin, which can worsen
hypotension by shifting fluid intracellularly.
Why not the others: A — insulin before adequate fluid resuscitation risks cardiovascular collapse. C — potassium must actually be
verified as adequate before insulin is started (insulin drives K into cells), not corrected first in isolation. D — bicarbonate isn’t
routine DKA therapy.
