HESI Exit Exam Comprehensive Review (RN/PN) –
200 Practice Questions with Detailed Rationales
Comprehensive RN/PN Exit Exam Review | 100%
Pass Guaranteed | Graded A+
1. A nurse is caring for a client who is receiving a blood transfusion and
develops fever, chills, and low back pain. Which of the following actions
should the nurse take first?
A. Administer acetaminophen
B. Stop the transfusion
C. Obtain a urine specimen
D. Notify the provider
ANS: B
Explanation: Fever, chills, and low back pain indicate a hemolytic transfusion
reaction. The first action is to stop the transfusion immediately to prevent further
hemolysis. Then the nurse should notify the provider (D), obtain a urine specimen
(C), and administer treatments as ordered (A).
2. A nurse is assessing a client who has heart failure and is receiving digoxin.
Which of the following findings should the nurse report to the provider?
A. Heart rate 72/min
B. Blood pressure 120/80 mm Hg
C. Nausea and vomiting
D. Serum potassium 4.0 mEq/L
ANS: C
Explanation: Nausea and vomiting are signs of digoxin toxicity, especially when
accompanied by visual disturbances and bradycardia. A heart rate of 72/min, blood
pressure of 120/80 mm Hg, and serum potassium of 4.0 mEq/L are within normal
limits.
, 3. A nurse is preparing to administer heparin subcutaneously. Which of the
following actions should the nurse take?
A. Aspirate before injecting the medication
B. Massage the site after the injection
C. Administer the injection in the abdomen at least 2 inches from the umbilicus
D. Use a 23-gauge, 1.5-inch needle
ANS: C
Explanation: Subcutaneous heparin should be administered in the abdomen, at
least 2 inches from the umbilicus, to ensure absorption and avoid irritation.
Aspiration (A) is not recommended. Massaging the site (B) can cause bruising and
hematoma. A 25-gauge, 3/8 to 5/8-inch needle (D) is used for subcutaneous
injections.
4. A nurse is assessing a client who has a new onset of confusion. Which of the
following actions should the nurse take first?
A. Determine the client's level of consciousness
B. Check the client's oxygen saturation
C. Review the client's medication list
D. Obtain a blood glucose level
ANS: A
Explanation: The nurse should first assess the client's level of consciousness to
establish a baseline and determine the severity of the confusion. Checking oxygen
saturation, reviewing medications, and obtaining blood glucose are important but
should follow the initial assessment.
5. A nurse is providing teaching to a client about the use of a cane. Which of the
following instructions should the nurse include?
A. Hold the cane on the weaker side
B. Move the cane forward 30 to 60 cm with each step
C. Hold the cane on the stronger side
D. Advance the cane and the weaker leg simultaneously
ANS: C
Explanation: The cane should be held on the stronger side to reduce the load on the
,weaker side. The cane is moved forward first, then the weaker leg, followed by the
stronger leg. The cane should be moved forward 15 to 30 cm with each step (B).
6. A nurse is caring for a client who has a wound drain. Which of the following
actions should the nurse take when emptying the drain?
A. Remove the drain from the wound
B. Empty the drain when it is half full
C. Use sterile technique when emptying the drain
D. Compress the drain before closing the port
ANS: D
Explanation: The drain should be compressed before closing the port to create
suction. The drain should not be removed from the wound (A). The drain should be
emptied when full or as ordered (B). Clean technique is typically used for emptying
a drain (C).
7. A nurse is assessing a client who has chronic pain. Which of the following is
the most reliable indicator of the client's pain?
A. The client's vital signs
B. The client's self-report of pain
C. The client's facial expression
D. The client's activity level
ANS: B
Explanation: The client's self-report is the most reliable indicator of pain. Vital
signs (A), facial expression (C), and activity level (D) are objective signs that may
not accurately reflect the client's pain experience.
8. A nurse is providing teaching to a client about the prevention of urinary tract
infections. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will wipe from back to front after using the toilet"
B. "I will empty my bladder every 4 hours"
C. "I will drink at least 2 liters of fluids per day"
D. "I will take a bubble bath to keep clean"
, ANS: C
Explanation: Drinking at least 2 liters of fluids per day helps flush bacteria from
the urinary tract. Wiping from back to front (A) is incorrect; it should be front to
back. Emptying the bladder every 4 hours (B) is too infrequent. Bubble baths (D)
can irritate the urethra.
9. A nurse is caring for a client who has a seizure disorder. Which of the
following actions should the nurse take during a seizure?
A. Insert a bite block into the client's mouth
B. Restrain the client's arms to prevent injury
C. Position the client on the side
D. Administer oral diazepam
ANS: C
Explanation: Positioning the client on the side helps maintain a patent airway and
allows oral secretions to drain. Inserting a bite block (A) is dangerous. Restraining
the client (B) can cause musculoskeletal injury. Oral diazepam (D) should not be
administered during a seizure.
10. A nurse is preparing to administer a tap water enema to a client. Which of
the following actions should the nurse take?
A. Administer the enema with the client in the supine position
B. Insert the tube 10 cm into the rectum
C. Use a solution temperature of 37.8°C
D. Instruct the client to retain the solution for 30 minutes
ANS: C
Explanation: The enema solution should be warmed to 37.8°C (100°F) to prevent
cramping and injury. The client should be in the left side-lying position (A). The
tube should be inserted 7 to 10 cm (B). The client should retain the solution for 5 to
15 minutes (D).
11. A nurse is assessing a client who is receiving total parenteral nutrition
(TPN). Which of the following findings indicates a complication of TPN
therapy?
200 Practice Questions with Detailed Rationales
Comprehensive RN/PN Exit Exam Review | 100%
Pass Guaranteed | Graded A+
1. A nurse is caring for a client who is receiving a blood transfusion and
develops fever, chills, and low back pain. Which of the following actions
should the nurse take first?
A. Administer acetaminophen
B. Stop the transfusion
C. Obtain a urine specimen
D. Notify the provider
ANS: B
Explanation: Fever, chills, and low back pain indicate a hemolytic transfusion
reaction. The first action is to stop the transfusion immediately to prevent further
hemolysis. Then the nurse should notify the provider (D), obtain a urine specimen
(C), and administer treatments as ordered (A).
2. A nurse is assessing a client who has heart failure and is receiving digoxin.
Which of the following findings should the nurse report to the provider?
A. Heart rate 72/min
B. Blood pressure 120/80 mm Hg
C. Nausea and vomiting
D. Serum potassium 4.0 mEq/L
ANS: C
Explanation: Nausea and vomiting are signs of digoxin toxicity, especially when
accompanied by visual disturbances and bradycardia. A heart rate of 72/min, blood
pressure of 120/80 mm Hg, and serum potassium of 4.0 mEq/L are within normal
limits.
, 3. A nurse is preparing to administer heparin subcutaneously. Which of the
following actions should the nurse take?
A. Aspirate before injecting the medication
B. Massage the site after the injection
C. Administer the injection in the abdomen at least 2 inches from the umbilicus
D. Use a 23-gauge, 1.5-inch needle
ANS: C
Explanation: Subcutaneous heparin should be administered in the abdomen, at
least 2 inches from the umbilicus, to ensure absorption and avoid irritation.
Aspiration (A) is not recommended. Massaging the site (B) can cause bruising and
hematoma. A 25-gauge, 3/8 to 5/8-inch needle (D) is used for subcutaneous
injections.
4. A nurse is assessing a client who has a new onset of confusion. Which of the
following actions should the nurse take first?
A. Determine the client's level of consciousness
B. Check the client's oxygen saturation
C. Review the client's medication list
D. Obtain a blood glucose level
ANS: A
Explanation: The nurse should first assess the client's level of consciousness to
establish a baseline and determine the severity of the confusion. Checking oxygen
saturation, reviewing medications, and obtaining blood glucose are important but
should follow the initial assessment.
5. A nurse is providing teaching to a client about the use of a cane. Which of the
following instructions should the nurse include?
A. Hold the cane on the weaker side
B. Move the cane forward 30 to 60 cm with each step
C. Hold the cane on the stronger side
D. Advance the cane and the weaker leg simultaneously
ANS: C
Explanation: The cane should be held on the stronger side to reduce the load on the
,weaker side. The cane is moved forward first, then the weaker leg, followed by the
stronger leg. The cane should be moved forward 15 to 30 cm with each step (B).
6. A nurse is caring for a client who has a wound drain. Which of the following
actions should the nurse take when emptying the drain?
A. Remove the drain from the wound
B. Empty the drain when it is half full
C. Use sterile technique when emptying the drain
D. Compress the drain before closing the port
ANS: D
Explanation: The drain should be compressed before closing the port to create
suction. The drain should not be removed from the wound (A). The drain should be
emptied when full or as ordered (B). Clean technique is typically used for emptying
a drain (C).
7. A nurse is assessing a client who has chronic pain. Which of the following is
the most reliable indicator of the client's pain?
A. The client's vital signs
B. The client's self-report of pain
C. The client's facial expression
D. The client's activity level
ANS: B
Explanation: The client's self-report is the most reliable indicator of pain. Vital
signs (A), facial expression (C), and activity level (D) are objective signs that may
not accurately reflect the client's pain experience.
8. A nurse is providing teaching to a client about the prevention of urinary tract
infections. Which of the following statements by the client indicates an
understanding of the teaching?
A. "I will wipe from back to front after using the toilet"
B. "I will empty my bladder every 4 hours"
C. "I will drink at least 2 liters of fluids per day"
D. "I will take a bubble bath to keep clean"
, ANS: C
Explanation: Drinking at least 2 liters of fluids per day helps flush bacteria from
the urinary tract. Wiping from back to front (A) is incorrect; it should be front to
back. Emptying the bladder every 4 hours (B) is too infrequent. Bubble baths (D)
can irritate the urethra.
9. A nurse is caring for a client who has a seizure disorder. Which of the
following actions should the nurse take during a seizure?
A. Insert a bite block into the client's mouth
B. Restrain the client's arms to prevent injury
C. Position the client on the side
D. Administer oral diazepam
ANS: C
Explanation: Positioning the client on the side helps maintain a patent airway and
allows oral secretions to drain. Inserting a bite block (A) is dangerous. Restraining
the client (B) can cause musculoskeletal injury. Oral diazepam (D) should not be
administered during a seizure.
10. A nurse is preparing to administer a tap water enema to a client. Which of
the following actions should the nurse take?
A. Administer the enema with the client in the supine position
B. Insert the tube 10 cm into the rectum
C. Use a solution temperature of 37.8°C
D. Instruct the client to retain the solution for 30 minutes
ANS: C
Explanation: The enema solution should be warmed to 37.8°C (100°F) to prevent
cramping and injury. The client should be in the left side-lying position (A). The
tube should be inserted 7 to 10 cm (B). The client should retain the solution for 5 to
15 minutes (D).
11. A nurse is assessing a client who is receiving total parenteral nutrition
(TPN). Which of the following findings indicates a complication of TPN
therapy?
