HESI RN EXIT EXAM V1 | 300 COMPLETE QUESTIONS AND
ANSWERS (VERIFIED ANSWERS) +RATIONALES |
COMPLETE EXAM PREP | GRADED Q&A 2026/2027 |
LATEST EXAM GUIDE 2026&2027
1. A nurse is caring for a client who is 4 hours postoperative following a total hip
replacement. Which finding requires immediate intervention?
A. Pain rated 5/10
B. Oxygen saturation of 96% on room air
C. Sudden onset of dyspnea and chest pain
D. Temperature of 37.4°C (99.3°F)
Answer: C
Sudden dyspnea and chest pain may indicate a pulmonary embolism, a potentially life-
threatening postoperative complication. The nurse should initiate immediate assessment and
emergency interventions.
2. A client with heart failure is prescribed furosemide. Which laboratory value is most
important for the nurse to monitor?
A. Potassium
B. Hemoglobin
C. Platelet count
D. Calcium
Answer: A
Furosemide is a loop diuretic that can cause significant potassium loss. Hypokalemia increases
the risk for dysrhythmias, making potassium monitoring a priority.
3. A nurse is assessing a client with suspected hypoglycemia. Which finding should the
nurse expect?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Deep, slow respirations
Answer: C
Hypoglycemia stimulates the sympathetic nervous system, producing diaphoresis, tremors,
tachycardia, hunger, anxiety, and weakness.
4. A client with chronic obstructive pulmonary disease is receiving oxygen. Which
oxygen saturation is generally an appropriate target for a client at risk for chronic
, carbon dioxide retention?
A. 100%
B. 95% to 99%
C. 88% to 92%
D. 75% to 80%
Answer: C
For many clients with COPD who are at risk for hypercapnia, controlled oxygen therapy
targeting approximately 88% to 92% helps correct hypoxemia while reducing the risk of
excessive oxygen administration.
5. A nurse is preparing to administer digoxin to an adult client. Which assessment is
the priority before administration?
A. Bowel sounds
B. Apical pulse
C. Skin turgor
D. Pupil response
Answer: B
Digoxin can cause bradycardia. The nurse should assess the apical pulse for a full minute and
follow prescribed parameters before administering the medication.
6. A client with diabetes mellitus is unconscious and has a blood glucose level of 38
mg/dL. Which intervention should the nurse anticipate?
A. Administer oral glucose
B. Give regular insulin
C. Administer IV dextrose or glucagon as indicated
D. Encourage the client to drink juice
Answer: C
An unconscious client cannot safely swallow. Rapid treatment with IV dextrose or glucagon,
depending on available access and orders, is appropriate for severe hypoglycemia.
7. A client receiving a blood transfusion develops chills, fever, and low back pain.
What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine specimen
Answer: B
,Fever, chills, and back pain may indicate an acute hemolytic transfusion reaction. The
transfusion must be stopped immediately, followed by maintaining IV access with
appropriate fluid and notifying the provider and blood bank according to protocol.
8. A nurse is caring for a client with increased intracranial pressure. Which
positioning intervention is appropriate?
A. Place the client flat
B. Elevate the head of the bed approximately 30 degrees
C. Flex the neck toward the chest
D. Place the client in Trendelenburg position
Answer: B
Elevating the head of the bed approximately 30 degrees while maintaining neutral head and
neck alignment can promote venous drainage and help reduce intracranial pressure.
9. A client taking warfarin has an INR of 5.8. Which action should the nurse take
first?
A. Administer the scheduled dose
B. Encourage foods high in vitamin K
C. Hold the medication and notify the provider
D. Administer aspirin
Answer: C
An INR of 5.8 indicates excessive anticoagulation and an increased bleeding risk. The nurse
should withhold the dose and promptly notify the provider for further management.
10. A client with pneumonia has a respiratory rate of 32/min, oxygen saturation of 86%,
and increasing confusion. Which action has the highest priority?
A. Encourage oral fluids
B. Apply oxygen as prescribed and assess respiratory status
C. Obtain a dietary history
D. Assist the client with ambulation
Answer: B
The client demonstrates significant respiratory compromise. Oxygenation and
airway/breathing assessment take priority over routine interventions.
11. A nurse is teaching a client newly prescribed lisinopril. Which statement indicates
understanding?
A. "I should report swelling of my lips or tongue."
B. "I should stop taking the medication when my blood pressure improves."
C. "I should expect severe constipation."
D. "I should take potassium supplements automatically."
, Answer: A
Angioedema involving the lips, tongue, or airway is a potentially life-threatening adverse
effect of ACE inhibitors and requires immediate medical attention.
12. A client with a potassium level of 2.8 mEq/L is receiving cardiac monitoring. Which
finding is most concerning?
A. Mild thirst
B. Flattened T waves and dysrhythmias
C. Increased appetite
D. Warm extremities
Answer: B
Severe hypokalemia can produce ECG changes and potentially life-threatening cardiac
dysrhythmias. Continuous cardiac monitoring may be required depending on severity and
clinical condition.
13. A postoperative client suddenly becomes restless and reports difficulty breathing.
The nurse notes a respiratory rate of 30/min. What should the nurse do first?
A. Assess airway and oxygenation
B. Administer prescribed analgesic
C. Encourage sleep
D. Offer oral fluids
Answer: A
Acute respiratory difficulty requires immediate assessment of airway, breathing, and
oxygenation before less urgent interventions.
14. A nurse is caring for a client with a chest tube. Which finding requires immediate
follow-up?
A. Tidaling in the water-seal chamber
B. Gentle bubbling with coughing
C. Continuous vigorous bubbling in the water-seal chamber
D. Drainage in the collection chamber
Answer: C
Continuous vigorous bubbling in the water-seal chamber can indicate an air leak. The nurse
should assess the system systematically to identify the source.
15. A client with a new tracheostomy has thick secretions and an oxygen saturation of
89%. Which intervention is most appropriate?
A. Restrict fluids
B. Suction the airway using sterile technique as indicated
ANSWERS (VERIFIED ANSWERS) +RATIONALES |
COMPLETE EXAM PREP | GRADED Q&A 2026/2027 |
LATEST EXAM GUIDE 2026&2027
1. A nurse is caring for a client who is 4 hours postoperative following a total hip
replacement. Which finding requires immediate intervention?
A. Pain rated 5/10
B. Oxygen saturation of 96% on room air
C. Sudden onset of dyspnea and chest pain
D. Temperature of 37.4°C (99.3°F)
Answer: C
Sudden dyspnea and chest pain may indicate a pulmonary embolism, a potentially life-
threatening postoperative complication. The nurse should initiate immediate assessment and
emergency interventions.
2. A client with heart failure is prescribed furosemide. Which laboratory value is most
important for the nurse to monitor?
A. Potassium
B. Hemoglobin
C. Platelet count
D. Calcium
Answer: A
Furosemide is a loop diuretic that can cause significant potassium loss. Hypokalemia increases
the risk for dysrhythmias, making potassium monitoring a priority.
3. A nurse is assessing a client with suspected hypoglycemia. Which finding should the
nurse expect?
A. Warm, dry skin
B. Bradycardia
C. Diaphoresis and tremors
D. Deep, slow respirations
Answer: C
Hypoglycemia stimulates the sympathetic nervous system, producing diaphoresis, tremors,
tachycardia, hunger, anxiety, and weakness.
4. A client with chronic obstructive pulmonary disease is receiving oxygen. Which
oxygen saturation is generally an appropriate target for a client at risk for chronic
, carbon dioxide retention?
A. 100%
B. 95% to 99%
C. 88% to 92%
D. 75% to 80%
Answer: C
For many clients with COPD who are at risk for hypercapnia, controlled oxygen therapy
targeting approximately 88% to 92% helps correct hypoxemia while reducing the risk of
excessive oxygen administration.
5. A nurse is preparing to administer digoxin to an adult client. Which assessment is
the priority before administration?
A. Bowel sounds
B. Apical pulse
C. Skin turgor
D. Pupil response
Answer: B
Digoxin can cause bradycardia. The nurse should assess the apical pulse for a full minute and
follow prescribed parameters before administering the medication.
6. A client with diabetes mellitus is unconscious and has a blood glucose level of 38
mg/dL. Which intervention should the nurse anticipate?
A. Administer oral glucose
B. Give regular insulin
C. Administer IV dextrose or glucagon as indicated
D. Encourage the client to drink juice
Answer: C
An unconscious client cannot safely swallow. Rapid treatment with IV dextrose or glucagon,
depending on available access and orders, is appropriate for severe hypoglycemia.
7. A client receiving a blood transfusion develops chills, fever, and low back pain.
What is the nurse's priority action?
A. Slow the transfusion
B. Stop the transfusion
C. Administer acetaminophen
D. Obtain a urine specimen
Answer: B
,Fever, chills, and back pain may indicate an acute hemolytic transfusion reaction. The
transfusion must be stopped immediately, followed by maintaining IV access with
appropriate fluid and notifying the provider and blood bank according to protocol.
8. A nurse is caring for a client with increased intracranial pressure. Which
positioning intervention is appropriate?
A. Place the client flat
B. Elevate the head of the bed approximately 30 degrees
C. Flex the neck toward the chest
D. Place the client in Trendelenburg position
Answer: B
Elevating the head of the bed approximately 30 degrees while maintaining neutral head and
neck alignment can promote venous drainage and help reduce intracranial pressure.
9. A client taking warfarin has an INR of 5.8. Which action should the nurse take
first?
A. Administer the scheduled dose
B. Encourage foods high in vitamin K
C. Hold the medication and notify the provider
D. Administer aspirin
Answer: C
An INR of 5.8 indicates excessive anticoagulation and an increased bleeding risk. The nurse
should withhold the dose and promptly notify the provider for further management.
10. A client with pneumonia has a respiratory rate of 32/min, oxygen saturation of 86%,
and increasing confusion. Which action has the highest priority?
A. Encourage oral fluids
B. Apply oxygen as prescribed and assess respiratory status
C. Obtain a dietary history
D. Assist the client with ambulation
Answer: B
The client demonstrates significant respiratory compromise. Oxygenation and
airway/breathing assessment take priority over routine interventions.
11. A nurse is teaching a client newly prescribed lisinopril. Which statement indicates
understanding?
A. "I should report swelling of my lips or tongue."
B. "I should stop taking the medication when my blood pressure improves."
C. "I should expect severe constipation."
D. "I should take potassium supplements automatically."
, Answer: A
Angioedema involving the lips, tongue, or airway is a potentially life-threatening adverse
effect of ACE inhibitors and requires immediate medical attention.
12. A client with a potassium level of 2.8 mEq/L is receiving cardiac monitoring. Which
finding is most concerning?
A. Mild thirst
B. Flattened T waves and dysrhythmias
C. Increased appetite
D. Warm extremities
Answer: B
Severe hypokalemia can produce ECG changes and potentially life-threatening cardiac
dysrhythmias. Continuous cardiac monitoring may be required depending on severity and
clinical condition.
13. A postoperative client suddenly becomes restless and reports difficulty breathing.
The nurse notes a respiratory rate of 30/min. What should the nurse do first?
A. Assess airway and oxygenation
B. Administer prescribed analgesic
C. Encourage sleep
D. Offer oral fluids
Answer: A
Acute respiratory difficulty requires immediate assessment of airway, breathing, and
oxygenation before less urgent interventions.
14. A nurse is caring for a client with a chest tube. Which finding requires immediate
follow-up?
A. Tidaling in the water-seal chamber
B. Gentle bubbling with coughing
C. Continuous vigorous bubbling in the water-seal chamber
D. Drainage in the collection chamber
Answer: C
Continuous vigorous bubbling in the water-seal chamber can indicate an air leak. The nurse
should assess the system systematically to identify the source.
15. A client with a new tracheostomy has thick secretions and an oxygen saturation of
89%. Which intervention is most appropriate?
A. Restrict fluids
B. Suction the airway using sterile technique as indicated
