HESI RN EXIT EXAM V2 NGN QUESTIONS
WITH ANSWERS AND EXPLANATIONS
Question 1.
A nurse is reviewing care related to Toddler injury prevention. Which nursing action is
most appropriate?
A. Encourage participation in school activities physical activity and age-appropriate
self-care.
B. Lock medications cleaners firearms and small choking hazards out of reach.
C. Recommend completion of the age-appropriate HPV vaccine series.
D. Ensure state-required screening and follow-up are completed before or shortly after
discharge as appropriate.
Correct Answer: B. Lock medications cleaners firearms and small choking
hazards out of reach.
Explanation: For Toddler injury prevention, the response that most directly addresses the
identified problem is: Lock medications cleaners firearms and small choking hazards out of
reach. Health-promotion care emphasizes prevention, age-appropriate screening,
development, immunization, and early detection. The distractors are reasonable nursing
actions for related conditions, but they do not target the priority problem identified in this
stem. After acting, the nurse should reassess the client or situation, verify the response,
and escalate care if the expected result does not occur.
Question 2.
On an emergency department, the nurse encounters a situation involving High-alert
medication independent check. Which nursing action should be implemented first?
A. Place the client on contact precautions and clean equipment with an appropriate
sporicidal agent.
B. Use designated PPE and handling procedures for administration spills and excreta as
required.
C. Have a second qualified nurse independently verify the prescribed dose concentration
and pump settings when policy requires.
D. Remove sharps cords belts medications and other hazards and maintain the prescribed
level of observation.
Correct Answer: C. Have a second qualified nurse independently verify the
prescribed dose concentration and pump settings when policy requires.
Explanation: For High-alert medication independent check, the response that most
directly addresses the identified problem is: Have a second qualified nurse independently
verify the prescribed dose concentration and pump settings when policy requires. Safety
decisions should interrupt exposure or injury risk while maintaining appropriate
precautions and surveillance. The distractors are reasonable nursing actions for related
conditions, but they do not target the priority problem identified in this stem. After acting,
the nurse should reassess the client or situation, verify the response, and escalate care if
the expected result does not occur.
,Question 3.
A preceptor discusses Hospice goals with a new graduate nurse. Which proposed action
shows the best understanding?
A. Assign the float nurse stable clients whose needs match the nurse's prior experience.
B. Add a labeled late entry with the current date and time rather than altering the earlier
note.
C. Use a qualified interpreter rather than relying on a minor family member.
D. Treat distressing symptoms and honor the client's comfort-focused plan.
Correct Answer: D. Treat distressing symptoms and honor the client's
comfort-focused plan.
Explanation: For Hospice goals, the response that most directly addresses the identified
problem is: Treat distressing symptoms and honor the client's comfort-focused plan.
Management decisions should account for acuity, scope of practice, communication,
ethics, and RN accountability. The distractors are reasonable nursing actions for related
conditions, but they do not target the priority problem identified in this stem. After acting,
the nurse should reassess the client or situation, verify the response, and escalate care if
the expected result does not occur.
Question 4.
On an acute-care medical-surgical unit, the nurse encounters a situation involving
Respiratory alkalosis. Which nursing action should be implemented first?
A. Treat the cause of hyperventilation such as pain anxiety hypoxemia or ventilator
settings.
B. Avoid IM injections rectal procedures and unnecessary trauma and report active
bleeding.
C. Place severe symptomatic clients on seizure or cardiac precautions and give calcium as
ordered.
D. Notify the provider and follow acute coronary syndrome protocols when symptoms and
serial troponins indicate injury.
Correct Answer: A. Treat the cause of hyperventilation such as pain anxiety
hypoxemia or ventilator settings.
Explanation: For Respiratory alkalosis, the response that most directly addresses the
identified problem is: Treat the cause of hyperventilation such as pain anxiety hypoxemia
or ventilator settings. Risk-reduction questions depend on recognizing early complications,
abnormal trends, procedure-related hazards, and when escalation is required. The
distractors are reasonable nursing actions for related conditions, but they do not target the
priority problem identified in this stem. After acting, the nurse should reassess the client or
situation, verify the response, and escalate care if the expected result does not occur.
,Question 5.
Case scenario: On a telemetry unit, a 24-year-old client has home visits prioritize
immediate safety physiologic instability and ability to obtain needed care. After
recognizing the likely problem as Home-care prioritization, which action should the nurse
take first?
A. Give bedside or approved handoff with identifiers current condition recent changes and
priorities.
B. Visit the client with new dyspnea and rapid weight gain before a stable client needing
routine teaching.
C. Report reasonable suspicion to the designated child-protection authority and follow
policy.
D. Apply the same clinical criteria to clients with comparable needs.
Correct Answer: B. Visit the client with new dyspnea and rapid weight gain
before a stable client needing routine teaching.
Explanation: For Home-care prioritization, the response that most directly addresses the
identified problem is: Visit the client with new dyspnea and rapid weight gain before a
stable client needing routine teaching. Management decisions should account for acuity,
scope of practice, communication, ethics, and RN accountability. The distractors are
reasonable nursing actions for related conditions, but they do not target the priority
problem identified in this stem. After acting, the nurse should reassess the client or
situation, verify the response, and escalate care if the expected result does not occur.
Question 6.
Which nursing intervention is specifically appropriate for a client with Anorexia nervosa?
A. Identify the precipitating event assess safety and help the client develop a short-term
action plan.
B. Focus on feelings and reality-based needs rather than arguing about the belief.
C. Assess potassium hydration cardiac symptoms and frequency of purging behaviors.
D. Monitor medical stability nutrition and refeeding risk while using a structured
nonpunitive meal plan.
Correct Answer: D. Monitor medical stability nutrition and refeeding risk while
using a structured nonpunitive meal plan.
Explanation: For Anorexia nervosa, the response that most directly addresses the
identified problem is: Monitor medical stability nutrition and refeeding risk while using a
structured nonpunitive meal plan. Psychosocial nursing prioritizes immediate safety,
therapeutic communication, boundaries, dignity, and recovery-oriented support. The
distractors are reasonable nursing actions for related conditions, but they do not target the
priority problem identified in this stem. After acting, the nurse should reassess the client or
situation, verify the response, and escalate care if the expected result does not occur.
, Question 7.
Case scenario: The nurse synthesizes history, current assessment, and safety risks
suggesting Tension pneumothorax. Which immediate action best links cue recognition to
safe intervention?
A. Provide emergency decompression followed by chest drainage as ordered without
delaying for routine imaging in an unstable client.
B. Begin aggressive fluid replacement and insulin with electrolyte monitoring.
C. Stabilize airway circulation obtain large-bore access and prepare for transfusion and
endoscopy as needed.
D. Obtain cultures as ordered and start broad-spectrum IV antibiotics promptly.
Correct Answer: A. Provide emergency decompression followed by chest
drainage as ordered without delaying for routine imaging in an unstable client.
Explanation: For Tension pneumothorax, the response that most directly addresses the
identified problem is: Provide emergency decompression followed by chest drainage as
ordered without delaying for routine imaging in an unstable client. Physiological
adaptation priorities protect airway, breathing, circulation, perfusion, neurologic function,
and organ stability while definitive treatment proceeds. The distractors are reasonable
nursing actions for related conditions, but they do not target the priority problem identified
in this stem. After acting, the nurse should reassess the client or situation, verify the
response, and escalate care if the expected result does not occur.
Question 8.
During shift planning, the nurse identifies Troponin trend as a current concern. Which
action belongs in the care plan?
A. Support the wound reduce strain and notify the surgeon promptly.
B. Treat the cause of hyperventilation such as pain anxiety hypoxemia or ventilator
settings.
C. Notify the provider and follow acute coronary syndrome protocols when symptoms and
serial troponins indicate injury.
D. Address perfusion urgently and repeat lactate as ordered in suspected shock or sepsis.
Correct Answer: C. Notify the provider and follow acute coronary syndrome
protocols when symptoms and serial troponins indicate injury.
Explanation: For Troponin trend, the response that most directly addresses the identified
problem is: Notify the provider and follow acute coronary syndrome protocols when
symptoms and serial troponins indicate injury. Risk-reduction questions depend on
recognizing early complications, abnormal trends, procedure-related hazards, and when
escalation is required. The distractors are reasonable nursing actions for related
conditions, but they do not target the priority problem identified in this stem. After acting,
the nurse should reassess the client or situation, verify the response, and escalate care if
the expected result does not occur.
WITH ANSWERS AND EXPLANATIONS
Question 1.
A nurse is reviewing care related to Toddler injury prevention. Which nursing action is
most appropriate?
A. Encourage participation in school activities physical activity and age-appropriate
self-care.
B. Lock medications cleaners firearms and small choking hazards out of reach.
C. Recommend completion of the age-appropriate HPV vaccine series.
D. Ensure state-required screening and follow-up are completed before or shortly after
discharge as appropriate.
Correct Answer: B. Lock medications cleaners firearms and small choking
hazards out of reach.
Explanation: For Toddler injury prevention, the response that most directly addresses the
identified problem is: Lock medications cleaners firearms and small choking hazards out of
reach. Health-promotion care emphasizes prevention, age-appropriate screening,
development, immunization, and early detection. The distractors are reasonable nursing
actions for related conditions, but they do not target the priority problem identified in this
stem. After acting, the nurse should reassess the client or situation, verify the response,
and escalate care if the expected result does not occur.
Question 2.
On an emergency department, the nurse encounters a situation involving High-alert
medication independent check. Which nursing action should be implemented first?
A. Place the client on contact precautions and clean equipment with an appropriate
sporicidal agent.
B. Use designated PPE and handling procedures for administration spills and excreta as
required.
C. Have a second qualified nurse independently verify the prescribed dose concentration
and pump settings when policy requires.
D. Remove sharps cords belts medications and other hazards and maintain the prescribed
level of observation.
Correct Answer: C. Have a second qualified nurse independently verify the
prescribed dose concentration and pump settings when policy requires.
Explanation: For High-alert medication independent check, the response that most
directly addresses the identified problem is: Have a second qualified nurse independently
verify the prescribed dose concentration and pump settings when policy requires. Safety
decisions should interrupt exposure or injury risk while maintaining appropriate
precautions and surveillance. The distractors are reasonable nursing actions for related
conditions, but they do not target the priority problem identified in this stem. After acting,
the nurse should reassess the client or situation, verify the response, and escalate care if
the expected result does not occur.
,Question 3.
A preceptor discusses Hospice goals with a new graduate nurse. Which proposed action
shows the best understanding?
A. Assign the float nurse stable clients whose needs match the nurse's prior experience.
B. Add a labeled late entry with the current date and time rather than altering the earlier
note.
C. Use a qualified interpreter rather than relying on a minor family member.
D. Treat distressing symptoms and honor the client's comfort-focused plan.
Correct Answer: D. Treat distressing symptoms and honor the client's
comfort-focused plan.
Explanation: For Hospice goals, the response that most directly addresses the identified
problem is: Treat distressing symptoms and honor the client's comfort-focused plan.
Management decisions should account for acuity, scope of practice, communication,
ethics, and RN accountability. The distractors are reasonable nursing actions for related
conditions, but they do not target the priority problem identified in this stem. After acting,
the nurse should reassess the client or situation, verify the response, and escalate care if
the expected result does not occur.
Question 4.
On an acute-care medical-surgical unit, the nurse encounters a situation involving
Respiratory alkalosis. Which nursing action should be implemented first?
A. Treat the cause of hyperventilation such as pain anxiety hypoxemia or ventilator
settings.
B. Avoid IM injections rectal procedures and unnecessary trauma and report active
bleeding.
C. Place severe symptomatic clients on seizure or cardiac precautions and give calcium as
ordered.
D. Notify the provider and follow acute coronary syndrome protocols when symptoms and
serial troponins indicate injury.
Correct Answer: A. Treat the cause of hyperventilation such as pain anxiety
hypoxemia or ventilator settings.
Explanation: For Respiratory alkalosis, the response that most directly addresses the
identified problem is: Treat the cause of hyperventilation such as pain anxiety hypoxemia
or ventilator settings. Risk-reduction questions depend on recognizing early complications,
abnormal trends, procedure-related hazards, and when escalation is required. The
distractors are reasonable nursing actions for related conditions, but they do not target the
priority problem identified in this stem. After acting, the nurse should reassess the client or
situation, verify the response, and escalate care if the expected result does not occur.
,Question 5.
Case scenario: On a telemetry unit, a 24-year-old client has home visits prioritize
immediate safety physiologic instability and ability to obtain needed care. After
recognizing the likely problem as Home-care prioritization, which action should the nurse
take first?
A. Give bedside or approved handoff with identifiers current condition recent changes and
priorities.
B. Visit the client with new dyspnea and rapid weight gain before a stable client needing
routine teaching.
C. Report reasonable suspicion to the designated child-protection authority and follow
policy.
D. Apply the same clinical criteria to clients with comparable needs.
Correct Answer: B. Visit the client with new dyspnea and rapid weight gain
before a stable client needing routine teaching.
Explanation: For Home-care prioritization, the response that most directly addresses the
identified problem is: Visit the client with new dyspnea and rapid weight gain before a
stable client needing routine teaching. Management decisions should account for acuity,
scope of practice, communication, ethics, and RN accountability. The distractors are
reasonable nursing actions for related conditions, but they do not target the priority
problem identified in this stem. After acting, the nurse should reassess the client or
situation, verify the response, and escalate care if the expected result does not occur.
Question 6.
Which nursing intervention is specifically appropriate for a client with Anorexia nervosa?
A. Identify the precipitating event assess safety and help the client develop a short-term
action plan.
B. Focus on feelings and reality-based needs rather than arguing about the belief.
C. Assess potassium hydration cardiac symptoms and frequency of purging behaviors.
D. Monitor medical stability nutrition and refeeding risk while using a structured
nonpunitive meal plan.
Correct Answer: D. Monitor medical stability nutrition and refeeding risk while
using a structured nonpunitive meal plan.
Explanation: For Anorexia nervosa, the response that most directly addresses the
identified problem is: Monitor medical stability nutrition and refeeding risk while using a
structured nonpunitive meal plan. Psychosocial nursing prioritizes immediate safety,
therapeutic communication, boundaries, dignity, and recovery-oriented support. The
distractors are reasonable nursing actions for related conditions, but they do not target the
priority problem identified in this stem. After acting, the nurse should reassess the client or
situation, verify the response, and escalate care if the expected result does not occur.
, Question 7.
Case scenario: The nurse synthesizes history, current assessment, and safety risks
suggesting Tension pneumothorax. Which immediate action best links cue recognition to
safe intervention?
A. Provide emergency decompression followed by chest drainage as ordered without
delaying for routine imaging in an unstable client.
B. Begin aggressive fluid replacement and insulin with electrolyte monitoring.
C. Stabilize airway circulation obtain large-bore access and prepare for transfusion and
endoscopy as needed.
D. Obtain cultures as ordered and start broad-spectrum IV antibiotics promptly.
Correct Answer: A. Provide emergency decompression followed by chest
drainage as ordered without delaying for routine imaging in an unstable client.
Explanation: For Tension pneumothorax, the response that most directly addresses the
identified problem is: Provide emergency decompression followed by chest drainage as
ordered without delaying for routine imaging in an unstable client. Physiological
adaptation priorities protect airway, breathing, circulation, perfusion, neurologic function,
and organ stability while definitive treatment proceeds. The distractors are reasonable
nursing actions for related conditions, but they do not target the priority problem identified
in this stem. After acting, the nurse should reassess the client or situation, verify the
response, and escalate care if the expected result does not occur.
Question 8.
During shift planning, the nurse identifies Troponin trend as a current concern. Which
action belongs in the care plan?
A. Support the wound reduce strain and notify the surgeon promptly.
B. Treat the cause of hyperventilation such as pain anxiety hypoxemia or ventilator
settings.
C. Notify the provider and follow acute coronary syndrome protocols when symptoms and
serial troponins indicate injury.
D. Address perfusion urgently and repeat lactate as ordered in suspected shock or sepsis.
Correct Answer: C. Notify the provider and follow acute coronary syndrome
protocols when symptoms and serial troponins indicate injury.
Explanation: For Troponin trend, the response that most directly addresses the identified
problem is: Notify the provider and follow acute coronary syndrome protocols when
symptoms and serial troponins indicate injury. Risk-reduction questions depend on
recognizing early complications, abnormal trends, procedure-related hazards, and when
escalation is required. The distractors are reasonable nursing actions for related
conditions, but they do not target the priority problem identified in this stem. After acting,
the nurse should reassess the client or situation, verify the response, and escalate care if
the expected result does not occur.
