HESI RN EXIT NGN-STYLE AND CASE SCENARIOS V1
EXAM QUESTIONS WITH ANSWERS AND EXPLANATIONS
1. Based on safe entry-level practice, which response is most urgent for quality improvement after repeated
falls?
A. Analyze patterns and system factors, implement a targeted change, and measure whether fall rates improve
B. Respect an informed refusal by a client with decision-making capacity while explaining consequences and
alternatives
C. Delegate routine hygiene or vital-sign collection for a stable client after the RN assessment
D. Access and disclose only the minimum information needed for legitimate care or authorized operations
Correct Answer: A. Analyze patterns and system factors, implement a targeted change, and measure whether fall
rates improve
Rationale: Quality improvement is iterative and data driven, focusing on safer systems and measurable outcomes.
2. Which nursing response has the highest priority when managing beta-blocker therapy?
A. Monitor respirations, reflexes, urine output, and magnesium status during infusion
B. Review blood pressure, renal function, potassium, and pregnancy status as appropriate
C. Use the ordered weight-based protocol and monitor the designated coagulation assay and bleeding
D. Check heart rate and blood pressure before administration according to the treatment plan
Correct Answer: D. Check heart rate and blood pressure before administration according to the treatment plan
Rationale: Beta blockers reduce heart rate and blood pressure; abrupt withdrawal can worsen ischemia or
tachycardia.
3. Based on safe entry-level practice, which response is most urgent for discharge planning and transitions
of care?
A. Honor the competent client current wishes and use the directive/surrogate when decision-making capacity is
lost
B. Begin discharge planning early and address medications, equipment, follow-up, transportation, and ability to
perform care
C. Communicate current condition, recent changes, critical results, pending tests, and immediate concerns during
handoff
D. Assign the float nurse clients and tasks that match demonstrated competence and recent experience
Correct Answer: B. Begin discharge planning early and address medications, equipment, follow-up,
transportation, and ability to perform care
Rationale: Transitions are safer when barriers are identified early and responsibilities are coordinated before
discharge.
4. A client situation raises concern about sickle cell acute chest syndrome. What is the nurse best initial
response?
A. Give intramuscular epinephrine promptly and support airway, breathing, and circulation
B. Support airway and oxygenation immediately and prepare escalation when a child shows fatigue or poor air
movement
C. Prepare for immediate decompression in an unstable client with classic tension physiology
D. Support oxygenation, give appropriate analgesia/antibiotics, and arrange urgent evaluation including
transfusion strategy when indicated
Correct Answer: D. Support oxygenation, give appropriate analgesia/antibiotics, and arrange urgent evaluation
including transfusion strategy when indicated
Rationale: Acute chest syndrome is a life-threatening sickle cell complication requiring rapid respiratory and
hematologic management.
5. Which nursing response has the highest priority when managing confidentiality and electronic health
information?
A. Verify that the client appears informed and voluntarily signs; notify the provider if major questions remain
B. Assign the float nurse clients and tasks that match demonstrated competence and recent experience
C. Access and disclose only the minimum information needed for legitimate care or authorized operations
D. Use disaster triage to direct scarce resources toward victims with immediate, potentially survivable threats
,Correct Answer: C. Access and disclose only the minimum information needed for legitimate care or authorized
operations
Rationale: Privacy standards require appropriate access, minimum necessary disclosure, and secure handling of
health information.
6. Based on safe entry-level practice, which response is most urgent for opioid analgesia?
A. Administer at the prescribed rate and monitor renal function and levels/exposure according to the regimen
B. Assess sedation and respiratory status as carefully as the pain score
C. Check heart rate and blood pressure before administration according to the treatment plan
D. Monitor volume status, renal function, potassium, and magnesium during significant diuresis
Correct Answer: B. Assess sedation and respiratory status as carefully as the pain score
Rationale: Opioid safety requires monitoring for respiratory depression and balancing analgesia with function
and sedation.
7. A client situation raises concern about chain of command for unresolved safety concerns. What is the
nurse best initial response?
A. Escalate through the organizational chain when a serious client-safety concern remains unresolved
B. Assess the client first, take needed safety actions, notify appropriate clinicians, and follow reporting policy
C. Begin discharge planning early and address medications, equipment, follow-up, transportation, and ability to
perform care
D. Analyze patterns and system factors, implement a targeted change, and measure whether fall rates improve
Correct Answer: A. Escalate through the organizational chain when a serious client-safety concern remains
unresolved
Rationale: Nurses have a duty to advocate and escalate unresolved safety concerns using established channels.
8. A nurse is caring for a client in whom upper gastrointestinal hemorrhage is a central issue. Which
response should be prioritized?
A. Begin isotonic fluids, insulin, and electrolyte management while treating the trigger
B. Protect airway/circulation and establish rapid IV access for resuscitation and urgent source control
C. Activate rapid cardiac evaluation and obtain a 12-lead ECG while treating ischemia according to protocol
D. Activate the stroke pathway and obtain emergent brain imaging within the reperfusion time window
Correct Answer: B. Protect airway/circulation and establish rapid IV access for resuscitation and urgent source
control
Rationale: Major GI bleeding is an ABC emergency requiring resuscitation and rapid control of the bleeding
source.
9. During a change in condition involving catheter-associated urinary tract infection prevention, which
action should the nurse take first?
A. Protect the head, clear hazards, time the seizure, and avoid putting objects in the mouth
B. Maintain a closed system, unobstructed flow, and the drainage bag below bladder level
C. Keep oxygen away from flames and ignition sources and follow facility fire-response procedures
D. Disinfect the hub before access and use aseptic technique for central-line care
Correct Answer: B. Maintain a closed system, unobstructed flow, and the drainage bag below bladder level
Rationale: CAUTI prevention emphasizes appropriate indication, closed drainage, unobstructed flow, and early
removal.
10. A client situation raises concern about aminoglycoside therapy. What is the nurse best initial response?
A. Assess sedation and respiratory status as carefully as the pain score
B. Teach that therapeutic mood benefit usually takes time and assess suicide risk especially after initiation or dose
changes
C. Check heart rate and blood pressure before administration according to the treatment plan
D. Use renal-adjusted dosing and ordered drug-level monitoring when applicable
Correct Answer: D. Use renal-adjusted dosing and ordered drug-level monitoring when applicable
Rationale: Aminoglycosides can cause nephrotoxicity and ototoxicity, especially with accumulation or
interacting nephrotoxins.
11. A nurse is caring for a client in whom structured handoff communication is a central issue. Which
response should be prioritized?
A. Use a qualified medical interpreter rather than relying on a minor child for important clinical communication
B. Escalate through the organizational chain when a serious client-safety concern remains unresolved
, C. Communicate current condition, recent changes, critical results, pending tests, and immediate concerns during
handoff
D. Begin discharge planning early and address medications, equipment, follow-up, transportation, and ability to
perform care
Correct Answer: C. Communicate current condition, recent changes, critical results, pending tests, and
immediate concerns during handoff
Rationale: Structured handoff reduces omissions and supports continuity of care.
12. A client situation raises concern about surgical site and perioperative safety. What is the nurse best
initial response?
A. Protect the head, clear hazards, time the seizure, and avoid putting objects in the mouth
B. Start droplet precautions promptly for suspected meningococcal disease in addition to standard precautions
C. Complete identity, procedure, site, allergy, and consent verification before the procedure begins
D. Use required independent verification and infusion safeguards for high-alert medications such as insulin or
concentrated electrolytes
Correct Answer: C. Complete identity, procedure, site, allergy, and consent verification before the procedure
begins
Rationale: Perioperative checklists and time-outs prevent wrong-patient, wrong-procedure, and wrong-site
events.
13. During a change in condition involving restraints and least-restrictive care, which action should the
nurse take first?
A. Try less-restrictive alternatives and use restraints only when clinically justified and properly
ordered/monitored
B. Escalate through the organizational chain when a serious client-safety concern remains unresolved
C. See first the client with an acute airway, breathing, circulation, or neurologic threat
D. Delegate routine hygiene or vital-sign collection for a stable client after the RN assessment
Correct Answer: A. Try less-restrictive alternatives and use restraints only when clinically justified and properly
ordered/monitored
Rationale: Restraints carry physical and psychological risk and require strict indication, monitoring, and repeated
reassessment.
14. A client situation raises concern about rising intracranial pressure. What is the nurse best initial
response?
A. Massage a boggy uterus and activate the hemorrhage response while quantifying blood loss and supporting
circulation
B. Use early ambulation, prescribed prophylaxis, and leg exercises when not contraindicated
C. Check the fistula or graft for a bruit and thrill and protect the access arm
D. Maintain oxygenation, head alignment/elevation, and rapid neurologic reassessment when signs of rising
pressure appear
Correct Answer: D. Maintain oxygenation, head alignment/elevation, and rapid neurologic reassessment when
signs of rising pressure appear
Rationale: Early recognition of rising intracranial pressure is critical because herniation can rapidly become
irreversible.
15. A nurse is caring for a client in whom alcohol withdrawal is a central issue. Which response should be
prioritized?
A. Use a validated withdrawal assessment, seizure precautions, thiamine as ordered, and benzodiazepine-based
treatment when indicated
B. Search for an acute cause when cognition changes suddenly or fluctuates over hours to days
C. Reduce stimulation, set clear limits, provide simple choices, and address sleep/nutrition needs
D. Acknowledge the experience without validating it and assess whether commands involve harm
Correct Answer: A. Use a validated withdrawal assessment, seizure precautions, thiamine as ordered, and
benzodiazepine-based treatment when indicated
Rationale: Withdrawal treatment prevents complications while supporting nutrition, hydration, and longer-term
recovery planning.
16. Which nursing response has the highest priority when managing advance directives and surrogate
decision-making?
EXAM QUESTIONS WITH ANSWERS AND EXPLANATIONS
1. Based on safe entry-level practice, which response is most urgent for quality improvement after repeated
falls?
A. Analyze patterns and system factors, implement a targeted change, and measure whether fall rates improve
B. Respect an informed refusal by a client with decision-making capacity while explaining consequences and
alternatives
C. Delegate routine hygiene or vital-sign collection for a stable client after the RN assessment
D. Access and disclose only the minimum information needed for legitimate care or authorized operations
Correct Answer: A. Analyze patterns and system factors, implement a targeted change, and measure whether fall
rates improve
Rationale: Quality improvement is iterative and data driven, focusing on safer systems and measurable outcomes.
2. Which nursing response has the highest priority when managing beta-blocker therapy?
A. Monitor respirations, reflexes, urine output, and magnesium status during infusion
B. Review blood pressure, renal function, potassium, and pregnancy status as appropriate
C. Use the ordered weight-based protocol and monitor the designated coagulation assay and bleeding
D. Check heart rate and blood pressure before administration according to the treatment plan
Correct Answer: D. Check heart rate and blood pressure before administration according to the treatment plan
Rationale: Beta blockers reduce heart rate and blood pressure; abrupt withdrawal can worsen ischemia or
tachycardia.
3. Based on safe entry-level practice, which response is most urgent for discharge planning and transitions
of care?
A. Honor the competent client current wishes and use the directive/surrogate when decision-making capacity is
lost
B. Begin discharge planning early and address medications, equipment, follow-up, transportation, and ability to
perform care
C. Communicate current condition, recent changes, critical results, pending tests, and immediate concerns during
handoff
D. Assign the float nurse clients and tasks that match demonstrated competence and recent experience
Correct Answer: B. Begin discharge planning early and address medications, equipment, follow-up,
transportation, and ability to perform care
Rationale: Transitions are safer when barriers are identified early and responsibilities are coordinated before
discharge.
4. A client situation raises concern about sickle cell acute chest syndrome. What is the nurse best initial
response?
A. Give intramuscular epinephrine promptly and support airway, breathing, and circulation
B. Support airway and oxygenation immediately and prepare escalation when a child shows fatigue or poor air
movement
C. Prepare for immediate decompression in an unstable client with classic tension physiology
D. Support oxygenation, give appropriate analgesia/antibiotics, and arrange urgent evaluation including
transfusion strategy when indicated
Correct Answer: D. Support oxygenation, give appropriate analgesia/antibiotics, and arrange urgent evaluation
including transfusion strategy when indicated
Rationale: Acute chest syndrome is a life-threatening sickle cell complication requiring rapid respiratory and
hematologic management.
5. Which nursing response has the highest priority when managing confidentiality and electronic health
information?
A. Verify that the client appears informed and voluntarily signs; notify the provider if major questions remain
B. Assign the float nurse clients and tasks that match demonstrated competence and recent experience
C. Access and disclose only the minimum information needed for legitimate care or authorized operations
D. Use disaster triage to direct scarce resources toward victims with immediate, potentially survivable threats
,Correct Answer: C. Access and disclose only the minimum information needed for legitimate care or authorized
operations
Rationale: Privacy standards require appropriate access, minimum necessary disclosure, and secure handling of
health information.
6. Based on safe entry-level practice, which response is most urgent for opioid analgesia?
A. Administer at the prescribed rate and monitor renal function and levels/exposure according to the regimen
B. Assess sedation and respiratory status as carefully as the pain score
C. Check heart rate and blood pressure before administration according to the treatment plan
D. Monitor volume status, renal function, potassium, and magnesium during significant diuresis
Correct Answer: B. Assess sedation and respiratory status as carefully as the pain score
Rationale: Opioid safety requires monitoring for respiratory depression and balancing analgesia with function
and sedation.
7. A client situation raises concern about chain of command for unresolved safety concerns. What is the
nurse best initial response?
A. Escalate through the organizational chain when a serious client-safety concern remains unresolved
B. Assess the client first, take needed safety actions, notify appropriate clinicians, and follow reporting policy
C. Begin discharge planning early and address medications, equipment, follow-up, transportation, and ability to
perform care
D. Analyze patterns and system factors, implement a targeted change, and measure whether fall rates improve
Correct Answer: A. Escalate through the organizational chain when a serious client-safety concern remains
unresolved
Rationale: Nurses have a duty to advocate and escalate unresolved safety concerns using established channels.
8. A nurse is caring for a client in whom upper gastrointestinal hemorrhage is a central issue. Which
response should be prioritized?
A. Begin isotonic fluids, insulin, and electrolyte management while treating the trigger
B. Protect airway/circulation and establish rapid IV access for resuscitation and urgent source control
C. Activate rapid cardiac evaluation and obtain a 12-lead ECG while treating ischemia according to protocol
D. Activate the stroke pathway and obtain emergent brain imaging within the reperfusion time window
Correct Answer: B. Protect airway/circulation and establish rapid IV access for resuscitation and urgent source
control
Rationale: Major GI bleeding is an ABC emergency requiring resuscitation and rapid control of the bleeding
source.
9. During a change in condition involving catheter-associated urinary tract infection prevention, which
action should the nurse take first?
A. Protect the head, clear hazards, time the seizure, and avoid putting objects in the mouth
B. Maintain a closed system, unobstructed flow, and the drainage bag below bladder level
C. Keep oxygen away from flames and ignition sources and follow facility fire-response procedures
D. Disinfect the hub before access and use aseptic technique for central-line care
Correct Answer: B. Maintain a closed system, unobstructed flow, and the drainage bag below bladder level
Rationale: CAUTI prevention emphasizes appropriate indication, closed drainage, unobstructed flow, and early
removal.
10. A client situation raises concern about aminoglycoside therapy. What is the nurse best initial response?
A. Assess sedation and respiratory status as carefully as the pain score
B. Teach that therapeutic mood benefit usually takes time and assess suicide risk especially after initiation or dose
changes
C. Check heart rate and blood pressure before administration according to the treatment plan
D. Use renal-adjusted dosing and ordered drug-level monitoring when applicable
Correct Answer: D. Use renal-adjusted dosing and ordered drug-level monitoring when applicable
Rationale: Aminoglycosides can cause nephrotoxicity and ototoxicity, especially with accumulation or
interacting nephrotoxins.
11. A nurse is caring for a client in whom structured handoff communication is a central issue. Which
response should be prioritized?
A. Use a qualified medical interpreter rather than relying on a minor child for important clinical communication
B. Escalate through the organizational chain when a serious client-safety concern remains unresolved
, C. Communicate current condition, recent changes, critical results, pending tests, and immediate concerns during
handoff
D. Begin discharge planning early and address medications, equipment, follow-up, transportation, and ability to
perform care
Correct Answer: C. Communicate current condition, recent changes, critical results, pending tests, and
immediate concerns during handoff
Rationale: Structured handoff reduces omissions and supports continuity of care.
12. A client situation raises concern about surgical site and perioperative safety. What is the nurse best
initial response?
A. Protect the head, clear hazards, time the seizure, and avoid putting objects in the mouth
B. Start droplet precautions promptly for suspected meningococcal disease in addition to standard precautions
C. Complete identity, procedure, site, allergy, and consent verification before the procedure begins
D. Use required independent verification and infusion safeguards for high-alert medications such as insulin or
concentrated electrolytes
Correct Answer: C. Complete identity, procedure, site, allergy, and consent verification before the procedure
begins
Rationale: Perioperative checklists and time-outs prevent wrong-patient, wrong-procedure, and wrong-site
events.
13. During a change in condition involving restraints and least-restrictive care, which action should the
nurse take first?
A. Try less-restrictive alternatives and use restraints only when clinically justified and properly
ordered/monitored
B. Escalate through the organizational chain when a serious client-safety concern remains unresolved
C. See first the client with an acute airway, breathing, circulation, or neurologic threat
D. Delegate routine hygiene or vital-sign collection for a stable client after the RN assessment
Correct Answer: A. Try less-restrictive alternatives and use restraints only when clinically justified and properly
ordered/monitored
Rationale: Restraints carry physical and psychological risk and require strict indication, monitoring, and repeated
reassessment.
14. A client situation raises concern about rising intracranial pressure. What is the nurse best initial
response?
A. Massage a boggy uterus and activate the hemorrhage response while quantifying blood loss and supporting
circulation
B. Use early ambulation, prescribed prophylaxis, and leg exercises when not contraindicated
C. Check the fistula or graft for a bruit and thrill and protect the access arm
D. Maintain oxygenation, head alignment/elevation, and rapid neurologic reassessment when signs of rising
pressure appear
Correct Answer: D. Maintain oxygenation, head alignment/elevation, and rapid neurologic reassessment when
signs of rising pressure appear
Rationale: Early recognition of rising intracranial pressure is critical because herniation can rapidly become
irreversible.
15. A nurse is caring for a client in whom alcohol withdrawal is a central issue. Which response should be
prioritized?
A. Use a validated withdrawal assessment, seizure precautions, thiamine as ordered, and benzodiazepine-based
treatment when indicated
B. Search for an acute cause when cognition changes suddenly or fluctuates over hours to days
C. Reduce stimulation, set clear limits, provide simple choices, and address sleep/nutrition needs
D. Acknowledge the experience without validating it and assess whether commands involve harm
Correct Answer: A. Use a validated withdrawal assessment, seizure precautions, thiamine as ordered, and
benzodiazepine-based treatment when indicated
Rationale: Withdrawal treatment prevents complications while supporting nutrition, hydration, and longer-term
recovery planning.
16. Which nursing response has the highest priority when managing advance directives and surrogate
decision-making?
