RN HESI EXIT EXAM VERSION 2
2026/2027 QUESTIONS WITH CORRECT
ANSWERS
1. A client with chronic heart failure is prescribed digoxin. Which clinical manifestation should
the nurse recognize as the earliest sign of digoxin toxicity?
A. Visual disturbances, such as seeing yellow halos.
B. Cardiac arrhythmias and palpitations.
C. Significant sinus bradycardia below 50 bpm.
D. Anorexia, nausea, and vomiting.
Answer: D
Conceptual Explanation: Gastrointestinal symptoms like anorexia, nausea, and vomiting
are typically the earliest signs of digoxin toxicity, preceding cardiac and visual changes.
2. A client is receiving a magnesium sulfate infusion for the treatment of severe preeclampsia.
Which assessment finding requires immediate discontinuation of the infusion?
A. Absence of deep tendon reflexes.
B. Urinary output of 40 mL per hour.
,C. Blood pressure of 150/90 mmHg.
D. Respiratory rate of 14 breaths per minute.
Answer: A
Conceptual Explanation: Loss of deep tendon reflexes (DTRs) is a sign of magnesium
toxicity. Infusion must be stopped to prevent respiratory arrest.
3. A child with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action
should the nurse perform first?
A. Administer 100% oxygen via face mask.
B. Place the child in the knee-chest position.
C. Prepare for the administration of morphine sulfate.
D. Obtain a full set of vital signs.
Answer: B
Conceptual Explanation: The knee-chest position increases systemic vascular resistance,
which reduces the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
4. A nurse is caring for a client with bipolar disorder who has a lithium level of 1.8 mEq/L.
Which action is most appropriate?
A. Administer the next scheduled dose of lithium.
B. Increase fluid intake to 3,000 mL per day.
C. Hold the dose and notify the healthcare provider.
, D. Prepare for immediate hemodialysis.
Answer: C
Conceptual Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-
1.2 mEq/L) and indicates toxicity. The dose must be held.
5. A client with a head injury exhibits Cushing’s Triad. Which set of vital signs is consistent
with this finding?
A. BP 80/40, Pulse 120, RR 30.
B. BP 120/80, Pulse 80, RR 18.
C. BP 110/70, Pulse 110, RR 24.
D. BP 180/60, Pulse 50, RR 10 and irregular.
Answer: D
Conceptual Explanation: Cushing’s Triad consists of widening pulse pressure (increased
systolic BP), bradycardia, and irregular/slow respirations, signifying increased ICP.
6. Which task is most appropriate for the RN to delegate to an Unlicensed Assistive Personnel
(UAP)?
A. Assisting a stable post-op client with initial ambulation.
B. Feeding a client who has new-onset dysphagia.
C. Measuring and recording output from a Foley bag.
D. Evaluating the effectiveness of pain medication.
2026/2027 QUESTIONS WITH CORRECT
ANSWERS
1. A client with chronic heart failure is prescribed digoxin. Which clinical manifestation should
the nurse recognize as the earliest sign of digoxin toxicity?
A. Visual disturbances, such as seeing yellow halos.
B. Cardiac arrhythmias and palpitations.
C. Significant sinus bradycardia below 50 bpm.
D. Anorexia, nausea, and vomiting.
Answer: D
Conceptual Explanation: Gastrointestinal symptoms like anorexia, nausea, and vomiting
are typically the earliest signs of digoxin toxicity, preceding cardiac and visual changes.
2. A client is receiving a magnesium sulfate infusion for the treatment of severe preeclampsia.
Which assessment finding requires immediate discontinuation of the infusion?
A. Absence of deep tendon reflexes.
B. Urinary output of 40 mL per hour.
,C. Blood pressure of 150/90 mmHg.
D. Respiratory rate of 14 breaths per minute.
Answer: A
Conceptual Explanation: Loss of deep tendon reflexes (DTRs) is a sign of magnesium
toxicity. Infusion must be stopped to prevent respiratory arrest.
3. A child with Tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action
should the nurse perform first?
A. Administer 100% oxygen via face mask.
B. Place the child in the knee-chest position.
C. Prepare for the administration of morphine sulfate.
D. Obtain a full set of vital signs.
Answer: B
Conceptual Explanation: The knee-chest position increases systemic vascular resistance,
which reduces the right-to-left shunt and improves oxygenation during a ‘tet’ spell.
4. A nurse is caring for a client with bipolar disorder who has a lithium level of 1.8 mEq/L.
Which action is most appropriate?
A. Administer the next scheduled dose of lithium.
B. Increase fluid intake to 3,000 mL per day.
C. Hold the dose and notify the healthcare provider.
, D. Prepare for immediate hemodialysis.
Answer: C
Conceptual Explanation: A lithium level of 1.8 mEq/L is above the therapeutic range (0.6-
1.2 mEq/L) and indicates toxicity. The dose must be held.
5. A client with a head injury exhibits Cushing’s Triad. Which set of vital signs is consistent
with this finding?
A. BP 80/40, Pulse 120, RR 30.
B. BP 120/80, Pulse 80, RR 18.
C. BP 110/70, Pulse 110, RR 24.
D. BP 180/60, Pulse 50, RR 10 and irregular.
Answer: D
Conceptual Explanation: Cushing’s Triad consists of widening pulse pressure (increased
systolic BP), bradycardia, and irregular/slow respirations, signifying increased ICP.
6. Which task is most appropriate for the RN to delegate to an Unlicensed Assistive Personnel
(UAP)?
A. Assisting a stable post-op client with initial ambulation.
B. Feeding a client who has new-onset dysphagia.
C. Measuring and recording output from a Foley bag.
D. Evaluating the effectiveness of pain medication.
