2022/2023 HESI RN EXIT EXAM V4 FULL
160 QUESTIONS AND ANSWERS
SECTION I: FUNDAMENTALS & SAFETY (Q1–15)
1. A nurse is preparing to administer a blood transfusion. Which action is the priority before
initiation?
A. Verify the client's identity with two identifiers
B. Obtain baseline vital signs
C. Prime the tubing with 0.9% sodium chloride
D. Verify the blood product with a second nurse at the bedside
Rationale: While all steps are required, the priority safety action immediately before
hanging blood is independent double-verification of the product with a second licensed nurse at
the bedside. Baseline vitals and NS priming are essential but do not replace the double-check
that prevents a fatal hemolytic reaction.
2. Which finding requires immediate intervention in a client receiving a blood transfusion?
A. Temperature 99.8°F (37.7°C)
B. Urticaria and wheezing 15 minutes into the transfusion
C. Heart rate increase from 72 to 80 bpm
D. Mild chills at the start of the transfusion
Rationale: Urticaria and wheezing indicate an allergic/anaphylactic reaction. The nurse must
stop the transfusion immediately, maintain IV access with new tubing and NS, and notify the
provider. A low-grade fever and mild chills may be febrile non-hemolytic reactions but do not
require the same emergency response as airway involvement.
3. A nurse is teaching a client about fall prevention. Which statement indicates correct
understanding?
A. "I should use the call light only for emergencies."
B. "I will keep my personal items within reach and use the call light before getting up."
,C. "I can use the bedside table to steady myself when walking."
D. "I will wear my socks without shoes to prevent slipping."
Rationale: Keeping items within reach and calling for assistance before ambulating reduces
fall risk. Using furniture for support, wearing only socks (increases slip risk), and limiting call
light use to emergencies are unsafe.
4. The nurse is caring for a client with a new colostomy. Which assessment finding is most
concerning?
A. Stoma is pink and moist
B. Stoma is dusky/blue-black and dry
C. Small amount of serosanguineous drainage on the pouch
D. Output is liquid 24 hours post-op
Rationale: A healthy stoma is pink/red, moist, and shiny. A dusky, blue-black, dry stoma
indicates ischemia/necrosis and requires immediate provider notification. Liquid output in the
first 24 hours and minor serosanguineous drainage are expected.
5. Which action best prevents central line-associated bloodstream infection (CLABSI)?
A. Changing the dressing every 24 hours
B. Performing hand hygiene and using sterile technique with dressing changes
C. Flushing the line with sterile water
D. Using the line for routine blood draws
Rationale: Hand hygiene and sterile technique during insertion and maintenance are the
cornerstones of CLABSI prevention. Dressings are typically changed every 5–7 days (or sooner if
soiled/loose), lines are flushed with NS per policy, and minimizing access reduces infection risk.
6. A nurse is preparing to insert an indwelling urinary catheter. Which action is correct?
A. Cleanse the meatus with sterile solution using downward strokes
B. Inflate the balloon before confirming urine return
C. Advance the catheter until resistance is met, then inflate
D. Use clean gloves for the entire procedure
, Rationale: Cleansing should move from least to most contaminated (downward/away from
meatus). The balloon is inflated only after urine return confirms bladder placement. Sterile
gloves are required throughout. Advancing until resistance then inflating risks urethral injury.
7. A client is prescribed enoxaparin (Lovenox) subcutaneously. Which action is correct?
A. Massage the injection site after administration
B. Inject into the fatty tissue of the abdomen at least 2 inches from the umbilicus
C. Aspirate before injecting
D. Use a 1-inch, 21-gauge needle
Rationale: Enoxaparin is given in the abdominal "love handle" area, 2 inches from the
umbilicus, without aspiration, and without massaging (massage increases bruising/hematoma).
A short, fine-gauge needle (25–27G) is used.
8. Which client is at highest risk for developing a pressure injury?
A. A 45-year-old with a fractured ankle
B. A 78-year-old with incontinence, immobility, and poor nutrition
C. A 30-year-old post-appendectomy
D. A 60-year-old with well-controlled hypertension
Rationale: Pressure injury risk rises with immobility, moisture (incontinence), advanced age,
and poor nutrition. The combination in the 78-year-old places them at highest risk. The other
clients have fewer risk factors.
9. A nurse is caring for a client on contact precautions. Which PPE is required?
A. Gloves only
B. Mask and gloves
C. Gloves and gown
D. N95 respirator and goggles
Rationale: Contact precautions require gloves and a gown for any contact with the client or
their environment. N95 is for airborne precautions; mask and goggles are standard/droplet
components.
, 10. Which finding indicates a need to stop suctioning a client with a tracheostomy?
A. Heart rate drops from 88 to 52 bpm
B. Client coughs during suctioning
C. Small amount of clear secretions
D. Oxygen saturation 96%
Rationale: Bradycardia during suctioning indicates vagal stimulation/hypoxia and is a sign to
stop immediately and oxygenate the client. Coughing and mild secretions are expected; SpO2
96% is acceptable.
11. A nurse is teaching a client about a low-sodium diet. Which food should the client avoid?
A. Fresh apples
B. Canned soup
C. Plain baked chicken
D. Steamed broccoli
Rationale: Canned soups are high in sodium due to processing. Fresh fruits, unprocessed
meats, and fresh vegetables are low-sodium choices.
12. A client with an advance directive has a DNR order. The client develops respiratory distress.
Which action is appropriate?
A. Begin CPR immediately
B. Provide comfort measures and notify the provider/family per protocol
C. Intubate the client
D. Withhold all medications
Rationale: With a DNR order, CPR and intubation are withheld. The nurse provides
comfort/palliative measures and follows facility protocol. Withholding all medications is
incorrect—comfort medications are still given.
13. Which technique is correct when removing PPE?
A. Remove gloves after the gown
B. Remove gloves first, then goggles, gown, and mask (mask last)
160 QUESTIONS AND ANSWERS
SECTION I: FUNDAMENTALS & SAFETY (Q1–15)
1. A nurse is preparing to administer a blood transfusion. Which action is the priority before
initiation?
A. Verify the client's identity with two identifiers
B. Obtain baseline vital signs
C. Prime the tubing with 0.9% sodium chloride
D. Verify the blood product with a second nurse at the bedside
Rationale: While all steps are required, the priority safety action immediately before
hanging blood is independent double-verification of the product with a second licensed nurse at
the bedside. Baseline vitals and NS priming are essential but do not replace the double-check
that prevents a fatal hemolytic reaction.
2. Which finding requires immediate intervention in a client receiving a blood transfusion?
A. Temperature 99.8°F (37.7°C)
B. Urticaria and wheezing 15 minutes into the transfusion
C. Heart rate increase from 72 to 80 bpm
D. Mild chills at the start of the transfusion
Rationale: Urticaria and wheezing indicate an allergic/anaphylactic reaction. The nurse must
stop the transfusion immediately, maintain IV access with new tubing and NS, and notify the
provider. A low-grade fever and mild chills may be febrile non-hemolytic reactions but do not
require the same emergency response as airway involvement.
3. A nurse is teaching a client about fall prevention. Which statement indicates correct
understanding?
A. "I should use the call light only for emergencies."
B. "I will keep my personal items within reach and use the call light before getting up."
,C. "I can use the bedside table to steady myself when walking."
D. "I will wear my socks without shoes to prevent slipping."
Rationale: Keeping items within reach and calling for assistance before ambulating reduces
fall risk. Using furniture for support, wearing only socks (increases slip risk), and limiting call
light use to emergencies are unsafe.
4. The nurse is caring for a client with a new colostomy. Which assessment finding is most
concerning?
A. Stoma is pink and moist
B. Stoma is dusky/blue-black and dry
C. Small amount of serosanguineous drainage on the pouch
D. Output is liquid 24 hours post-op
Rationale: A healthy stoma is pink/red, moist, and shiny. A dusky, blue-black, dry stoma
indicates ischemia/necrosis and requires immediate provider notification. Liquid output in the
first 24 hours and minor serosanguineous drainage are expected.
5. Which action best prevents central line-associated bloodstream infection (CLABSI)?
A. Changing the dressing every 24 hours
B. Performing hand hygiene and using sterile technique with dressing changes
C. Flushing the line with sterile water
D. Using the line for routine blood draws
Rationale: Hand hygiene and sterile technique during insertion and maintenance are the
cornerstones of CLABSI prevention. Dressings are typically changed every 5–7 days (or sooner if
soiled/loose), lines are flushed with NS per policy, and minimizing access reduces infection risk.
6. A nurse is preparing to insert an indwelling urinary catheter. Which action is correct?
A. Cleanse the meatus with sterile solution using downward strokes
B. Inflate the balloon before confirming urine return
C. Advance the catheter until resistance is met, then inflate
D. Use clean gloves for the entire procedure
, Rationale: Cleansing should move from least to most contaminated (downward/away from
meatus). The balloon is inflated only after urine return confirms bladder placement. Sterile
gloves are required throughout. Advancing until resistance then inflating risks urethral injury.
7. A client is prescribed enoxaparin (Lovenox) subcutaneously. Which action is correct?
A. Massage the injection site after administration
B. Inject into the fatty tissue of the abdomen at least 2 inches from the umbilicus
C. Aspirate before injecting
D. Use a 1-inch, 21-gauge needle
Rationale: Enoxaparin is given in the abdominal "love handle" area, 2 inches from the
umbilicus, without aspiration, and without massaging (massage increases bruising/hematoma).
A short, fine-gauge needle (25–27G) is used.
8. Which client is at highest risk for developing a pressure injury?
A. A 45-year-old with a fractured ankle
B. A 78-year-old with incontinence, immobility, and poor nutrition
C. A 30-year-old post-appendectomy
D. A 60-year-old with well-controlled hypertension
Rationale: Pressure injury risk rises with immobility, moisture (incontinence), advanced age,
and poor nutrition. The combination in the 78-year-old places them at highest risk. The other
clients have fewer risk factors.
9. A nurse is caring for a client on contact precautions. Which PPE is required?
A. Gloves only
B. Mask and gloves
C. Gloves and gown
D. N95 respirator and goggles
Rationale: Contact precautions require gloves and a gown for any contact with the client or
their environment. N95 is for airborne precautions; mask and goggles are standard/droplet
components.
, 10. Which finding indicates a need to stop suctioning a client with a tracheostomy?
A. Heart rate drops from 88 to 52 bpm
B. Client coughs during suctioning
C. Small amount of clear secretions
D. Oxygen saturation 96%
Rationale: Bradycardia during suctioning indicates vagal stimulation/hypoxia and is a sign to
stop immediately and oxygenate the client. Coughing and mild secretions are expected; SpO2
96% is acceptable.
11. A nurse is teaching a client about a low-sodium diet. Which food should the client avoid?
A. Fresh apples
B. Canned soup
C. Plain baked chicken
D. Steamed broccoli
Rationale: Canned soups are high in sodium due to processing. Fresh fruits, unprocessed
meats, and fresh vegetables are low-sodium choices.
12. A client with an advance directive has a DNR order. The client develops respiratory distress.
Which action is appropriate?
A. Begin CPR immediately
B. Provide comfort measures and notify the provider/family per protocol
C. Intubate the client
D. Withhold all medications
Rationale: With a DNR order, CPR and intubation are withheld. The nurse provides
comfort/palliative measures and follows facility protocol. Withholding all medications is
incorrect—comfort medications are still given.
13. Which technique is correct when removing PPE?
A. Remove gloves after the gown
B. Remove gloves first, then goggles, gown, and mask (mask last)
