HESI Exit RN V1 Exam Actual Exam
2026/2027 – All 160 Questions with
Answers & Detailed Rationales – Pass
Guaranteed – A+ Graded INSTANT
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1. Client with Anaphylaxis During Blood Transfusion
Question: A client receiving a blood transfusion begins to exhibit
signs of anaphylaxis. What is the nurse's priority action?
A. Slow the transfusion rate and continue to monitor vital signs.
B. Stop the transfusion immediately and disconnect the IV line.
C. Stop the transfusion immediately but keep the IV line open
with normal saline.
D. Continue the transfusion and prepare to administer
epinephrine.
Correct Answer: C
Rationale: In anaphylaxis, the transfusion must be stopped
immediately. However, it is critical to maintain IV access with a
normal saline infusion to have a route for emergency medications
like epinephrine. Disconnecting the line (B) would lose this access,
and continuing or slowing the transfusion (A, D) is unsafe.
,2. Preventing Peristomal Skin Breakdown
Question: For a patient with a new colostomy, which nursing
intervention is most effective in preventing peristomal skin
breakdown?
A. Apply a skin barrier product to the peristomal area.
B. Cleanse the stoma with antimicrobial soap.
C. Measure the stoma weekly to ensure proper pouch fit.
D. Place a heating pad over the stoma to improve circulation.
Correct Answer: A
Rationale: Applying a skin barrier (e.g., paste, powder, or wafer)
protects the skin from contact with effluent, which is the primary
cause of breakdown. Antimicrobial soap (B) can be irritating,
measuring the stoma (C) is important but doesn't directly prevent
breakdown, and heat (D) can damage the skin.
3. Delegate Task to Unlicensed Assistive Personnel (UAP)
Question: The nurse assesses a client one hour after starting a
transfusion of packed red blood cells and determines that there
are no indications of a transfusion reaction. What instruction
should the nurse provide to the UAP who is working with the
nurse?
A. Notify the nurse when the transfusion has finished, so further
client assessment can be done.
B. Continue to measure the client's vital signs every thirty minutes
,until the transfusion is complete.
C. Monitor the client carefully for the next three hours and report
the onset of a reaction immediately.
D. Since a reaction did not occur, the priority is to maintain client
comfort during the transfusion.
Correct Answer: A
Rationale: The UAP should notify the nurse when the transfusion
is complete so the nurse can perform the required post-
transfusion assessment. Vital signs during a transfusion (B) and
monitoring for reactions (C) require clinical judgment and are
within the nurse's scope, not delegable to a UAP. Assuming no
further monitoring is needed (D) is dangerous, as reactions can be
delayed.
4. Postoperative Care and Urine Output
Question: The nurse is caring for a postoperative client. Which
finding requires immediate attention?
A. Pain score 5/10
B. Urine output 20 mL/hr
C. Slight incision redness
Correct Answer: B
Rationale: A urine output of less than 30 mL/hr may indicate
hypovolemia or renal impairment, which is a critical finding that
requires immediate assessment and intervention. Pain and slight
redness are expected postoperative findings that should be
monitored but are not as urgent.
, 5. Hypoglycemia Management
Question: A client with diabetes has a blood glucose of 45 mg/dL.
What is the nurse's priority action?
A. Administer 15 g of fast-acting carbohydrates
B. Administer insulin
C. Recheck the blood glucose in 15 minutes
Correct Answer: A
Rationale: A blood glucose of 45 mg/dL indicates severe
hypoglycemia, which requires immediate glucose replacement to
prevent further neurological compromise. Fast-acting
carbohydrates (such as glucose tablets, juice, or regular soda) are
the standard initial treatment.
6. Infection Indicator in Elderly Clients
Question: Which sign is most indicative of infection in an elderly
client?
A. Fever
B. Confusion
C. Increased WBC count
Correct Answer: B
2026/2027 – All 160 Questions with
Answers & Detailed Rationales – Pass
Guaranteed – A+ Graded INSTANT
DOWNLOAD
1. Client with Anaphylaxis During Blood Transfusion
Question: A client receiving a blood transfusion begins to exhibit
signs of anaphylaxis. What is the nurse's priority action?
A. Slow the transfusion rate and continue to monitor vital signs.
B. Stop the transfusion immediately and disconnect the IV line.
C. Stop the transfusion immediately but keep the IV line open
with normal saline.
D. Continue the transfusion and prepare to administer
epinephrine.
Correct Answer: C
Rationale: In anaphylaxis, the transfusion must be stopped
immediately. However, it is critical to maintain IV access with a
normal saline infusion to have a route for emergency medications
like epinephrine. Disconnecting the line (B) would lose this access,
and continuing or slowing the transfusion (A, D) is unsafe.
,2. Preventing Peristomal Skin Breakdown
Question: For a patient with a new colostomy, which nursing
intervention is most effective in preventing peristomal skin
breakdown?
A. Apply a skin barrier product to the peristomal area.
B. Cleanse the stoma with antimicrobial soap.
C. Measure the stoma weekly to ensure proper pouch fit.
D. Place a heating pad over the stoma to improve circulation.
Correct Answer: A
Rationale: Applying a skin barrier (e.g., paste, powder, or wafer)
protects the skin from contact with effluent, which is the primary
cause of breakdown. Antimicrobial soap (B) can be irritating,
measuring the stoma (C) is important but doesn't directly prevent
breakdown, and heat (D) can damage the skin.
3. Delegate Task to Unlicensed Assistive Personnel (UAP)
Question: The nurse assesses a client one hour after starting a
transfusion of packed red blood cells and determines that there
are no indications of a transfusion reaction. What instruction
should the nurse provide to the UAP who is working with the
nurse?
A. Notify the nurse when the transfusion has finished, so further
client assessment can be done.
B. Continue to measure the client's vital signs every thirty minutes
,until the transfusion is complete.
C. Monitor the client carefully for the next three hours and report
the onset of a reaction immediately.
D. Since a reaction did not occur, the priority is to maintain client
comfort during the transfusion.
Correct Answer: A
Rationale: The UAP should notify the nurse when the transfusion
is complete so the nurse can perform the required post-
transfusion assessment. Vital signs during a transfusion (B) and
monitoring for reactions (C) require clinical judgment and are
within the nurse's scope, not delegable to a UAP. Assuming no
further monitoring is needed (D) is dangerous, as reactions can be
delayed.
4. Postoperative Care and Urine Output
Question: The nurse is caring for a postoperative client. Which
finding requires immediate attention?
A. Pain score 5/10
B. Urine output 20 mL/hr
C. Slight incision redness
Correct Answer: B
Rationale: A urine output of less than 30 mL/hr may indicate
hypovolemia or renal impairment, which is a critical finding that
requires immediate assessment and intervention. Pain and slight
redness are expected postoperative findings that should be
monitored but are not as urgent.
, 5. Hypoglycemia Management
Question: A client with diabetes has a blood glucose of 45 mg/dL.
What is the nurse's priority action?
A. Administer 15 g of fast-acting carbohydrates
B. Administer insulin
C. Recheck the blood glucose in 15 minutes
Correct Answer: A
Rationale: A blood glucose of 45 mg/dL indicates severe
hypoglycemia, which requires immediate glucose replacement to
prevent further neurological compromise. Fast-acting
carbohydrates (such as glucose tablets, juice, or regular soda) are
the standard initial treatment.
6. Infection Indicator in Elderly Clients
Question: Which sign is most indicative of infection in an elderly
client?
A. Fever
B. Confusion
C. Increased WBC count
Correct Answer: B
