HESI RN EXIT NGN-STYLE AND CASE SCENARIOS V4
EXAM QUESTIONS WITH ANSWERS AND EXPLANATIONS
1. When caring for a client with informed consent for a procedure, which action is appropriate?
A. Protect screens, passwords, printouts, and verbal discussions from unauthorized viewing
B. Confirm that the health care team has access to the most current directive
C. Assess understanding, provide information, notify the provider, and document the informed refusal
D. Use a qualified interpreter when language barriers affect consent
Correct Answer: D. Use a qualified interpreter when language barriers affect consent
Rationale: Informed consent requires capacity, adequate information, understanding, and voluntariness; the nurse
witnesses and advocates rather than replacing the provider explanation.
2. Which clinical decision best applies safe practice to rapid-acting insulin?
A. Hold the dose and notify the prescriber when clinically significant bradycardia or toxicity is suspected
B. Support ventilation and administer naloxone for clinically significant opioid-induced respiratory depression
C. Recheck glucose after treatment of hypoglycemia and identify the cause
D. Stop the infusion and prepare calcium gluconate when significant magnesium toxicity is suspected
Correct Answer: C. Recheck glucose after treatment of hypoglycemia and identify the cause
Rationale: Rapid-acting insulin has a quick onset; timing with meals and prompt treatment of hypoglycemia are
essential.
3. Which nursing intervention is most appropriate for delegation to assistive personnel?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Give clear directions, expected results, and specific findings that must be reported
C. Preserve relevant details and participate in nonpunitive analysis
D. Retain initial assessment, complex teaching, and rapidly changing clients for the RN
Correct Answer: B. Give clear directions, expected results, and specific findings that must be reported
Rationale: Delegation transfers performance of a task, not nursing accountability; unstable clients, assessment,
teaching, and evaluation remain RN responsibilities.
4. The plan of care addresses septic shock. Which action should the nurse include?
A. Repeat epinephrine and escalate airway/hemodynamic support when severe symptoms persist
B. Use norepinephrine as first-line vasopressor for persistent septic shock hypotension after appropriate fluids
C. Use manual elevation of the presenting part and appropriate maternal positioning while preparing operative
delivery
D. Prepare for reperfusion therapy when indicated and monitor for arrhythmia/shock
Correct Answer: B. Use norepinephrine as first-line vasopressor for persistent septic shock hypotension after
appropriate fluids
Rationale: Septic shock requires rapid infection treatment plus restoration of perfusion; norepinephrine is the
standard first-line vasopressor in most adults.
5. Which action by the nurse is most consistent with correct management of unfractionated heparin
infusion?
A. Stop heparin and follow protocol when serious bleeding or suspected HIT occurs
B. Hold the dose and notify the prescriber when clinically significant bradycardia or toxicity is suspected
C. Slow or stop the infusion and treat symptoms when an infusion reaction occurs, then resume per protocol if
appropriate
D. Hold/escalate therapy when significant nephrotoxicity or ototoxicity is suspected
Correct Answer: A. Stop heparin and follow protocol when serious bleeding or suspected HIT occurs
Rationale: Heparin therapy requires dose monitoring, bleeding assessment, and vigilance for heparin-induced
thrombocytopenia.
6. The plan of care addresses mass-casualty resource allocation. Which action should the nurse include?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Reassess triage categories because victim condition and resource availability change
C. Speak directly to the client and use plain language while the interpreter facilitates communication
D. Use case management, pharmacy, social work, or home health when needs cross disciplines
Correct Answer: B. Reassess triage categories because victim condition and resource availability change
,Rationale: Disaster triage differs from routine care because the goal is population-level benefit under constrained
resources.
7. Which nursing intervention is most appropriate for central-line infection prevention?
A. After convulsions stop, position for airway protection and assess breathing
B. Document the exposure circumstances and source information according to policy
C. Keep sterile items above waist level and within continuous view
D. Assess daily whether the central line is still necessary
Correct Answer: D. Assess daily whether the central line is still necessary
Rationale: CLABSI prevention combines insertion and maintenance bundles with daily necessity review.
8. Which action by the nurse is most consistent with correct management of end-of-life goals and hospice
referral?
A. Preserve relevant details and participate in nonpunitive analysis
B. Use case management, pharmacy, social work, or home health when needs cross disciplines
C. Coordinate symptom management and interdisciplinary support for the client and family
D. Ask about recent experience before finalizing the assignment
Correct Answer: C. Coordinate symptom management and interdisciplinary support for the client and family
Rationale: Goal-concordant care requires clear communication, respect for preferences, and appropriate
palliative/hospice support.
9. Which clinical decision best applies safe practice to acute ischemic stroke?
A. Use manual elevation of the presenting part and appropriate maternal positioning while preparing operative
delivery
B. Administer prescribed diuretic/vasodilator therapy and reassess respiratory response
C. Repeat epinephrine and escalate airway/hemodynamic support when severe symptoms persist
D. Maintain NPO status until swallow safety is assessed and follow ordered blood-pressure targets
Correct Answer: D. Maintain NPO status until swallow safety is assessed and follow ordered blood-pressure
targets
Rationale: Stroke outcomes depend on rapid imaging/reperfusion evaluation and prevention of secondary
complications.
10. Which nursing intervention is most appropriate for chain of command for unresolved safety concerns?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Give clear directions, expected results, and specific findings that must be reported
C. Confirm that the health care team has access to the most current directive
D. Ask about recent experience before finalizing the assignment
Correct Answer: A. State the concern clearly, cite objective findings, and document appropriate communication
Rationale: Nurses have a duty to advocate and escalate unresolved safety concerns using established channels.
11. Which action by the nurse is most consistent with correct management of oxytocin infusion?
A. Replace electrolytes or adjust therapy according to laboratory results and clinical status
B. Review interacting serotonergic drugs and monitor for serotonin toxicity
C. Hold the dose and notify the prescriber when clinically significant bradycardia or toxicity is suspected
D. Stop or reduce the infusion and begin intrauterine resuscitative measures for tachysystole with fetal
compromise
Correct Answer: D. Stop or reduce the infusion and begin intrauterine resuscitative measures for tachysystole
with fetal compromise
Rationale: Oxytocin requires close monitoring because excessive uterine activity can reduce uteroplacental
perfusion.
12. When caring for a client with near-miss reporting, which action is appropriate?
A. Preserve relevant details and participate in nonpunitive analysis
B. Document the client response and care provided without blaming language
C. Use case management, pharmacy, social work, or home health when needs cross disciplines
D. Protect screens, passwords, printouts, and verbal discussions from unauthorized viewing
Correct Answer: A. Preserve relevant details and participate in nonpunitive analysis
Rationale: Near-miss data support proactive safety improvement and learning.
13. Which intervention best reflects current nursing management of newborn safe sleep?
, A. Offer guideline-based vaccination and screening while respecting adolescent confidentiality laws
B. Use stair gates, window guards, and safe water practices appropriate to the home
C. Teach home blood-pressure technique when appropriate and review medication adherence
D. Reinforce safe sleep at every caregiver encounter
Correct Answer: D. Reinforce safe sleep at every caregiver encounter
Rationale: Safe-sleep practices reduce sleep-related infant deaths and avoid suffocation hazards.
14. When caring for a client with alcohol withdrawal, which action is appropriate?
A. Offer portable nutrient-dense foods and brief, concrete communication
B. Reduce environmental stimulation and monitor fluids, electrolytes, and autonomic signs
C. After symptoms decrease, explore triggers and coping strategies
D. Promote orientation, sleep, mobility, hydration, and sensory aids while treating the cause
Correct Answer: B. Reduce environmental stimulation and monitor fluids, electrolytes, and autonomic signs
Rationale: Withdrawal treatment prevents complications while supporting nutrition, hydration, and longer-term
recovery planning.
15. Which intervention best reflects current nursing management of seizure safety?
A. Assess daily whether the central line is still necessary
B. Use nonskid footwear and purposeful rounding rather than relying on restraints
C. After convulsions stop, position for airway protection and assess breathing
D. Limit transport and mask the client when transport is necessary
Correct Answer: C. After convulsions stop, position for airway protection and assess breathing
Rationale: Seizure safety focuses on preventing injury, maintaining airway/oxygenation, and observing the event
accurately.
16. The plan of care addresses assignment to an LPN/LVN. Which action should the nurse include?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Assess understanding, provide information, notify the provider, and document the informed refusal
C. Protect screens, passwords, printouts, and verbal discussions from unauthorized viewing
D. Retain initial assessment, complex teaching, and rapidly changing clients for the RN
Correct Answer: D. Retain initial assessment, complex teaching, and rapidly changing clients for the RN
Rationale: Assignment should match scope, competence, client stability, and predictability of outcomes.
17. When caring for a client with post-cardiac-catheterization bleeding, which action is appropriate?
A. Verify identity and blood-product information at the bedside before starting the product
B. Maintain ordered activity restrictions and monitor pulses, color, warmth, and bleeding
C. Use continuous cardiac monitoring during severe hyperkalemia treatment
D. Stop uterotonic stimulation and initiate appropriate intrauterine resuscitative measures when indicated
Correct Answer: B. Maintain ordered activity restrictions and monitor pulses, color, warmth, and bleeding
Rationale: Cardiac catheterization can cause access-site or retroperitoneal bleeding and limb ischemia, requiring
prompt recognition.
18. Which intervention best reflects current nursing management of diabetic ketoacidosis?
A. Use incentive spirometry during hospitalization for vaso-occlusive pain when appropriate to reduce pulmonary
complications
B. Delay insulin only when severe hypokalemia requires correction first, then continue protocolized treatment
C. Repeat epinephrine and escalate airway/hemodynamic support when severe symptoms persist
D. Assess for systemic inflammatory complications rather than using lipase value alone to judge severity
Correct Answer: B. Delay insulin only when severe hypokalemia requires correction first, then continue
protocolized treatment
Rationale: DKA treatment corrects dehydration and ketosis while carefully managing potassium and the
precipitating illness.
19. Which nursing intervention is most appropriate for phenytoin therapy?
A. Hold the dose and obtain urgent evaluation when toxicity is suspected
B. Hold and escalate promptly when angioedema is suspected
C. Review drug levels, interactions, and albumin status when toxicity or loss of control is suspected
D. Slow or stop the infusion and treat symptoms when an infusion reaction occurs, then resume per protocol if
appropriate
EXAM QUESTIONS WITH ANSWERS AND EXPLANATIONS
1. When caring for a client with informed consent for a procedure, which action is appropriate?
A. Protect screens, passwords, printouts, and verbal discussions from unauthorized viewing
B. Confirm that the health care team has access to the most current directive
C. Assess understanding, provide information, notify the provider, and document the informed refusal
D. Use a qualified interpreter when language barriers affect consent
Correct Answer: D. Use a qualified interpreter when language barriers affect consent
Rationale: Informed consent requires capacity, adequate information, understanding, and voluntariness; the nurse
witnesses and advocates rather than replacing the provider explanation.
2. Which clinical decision best applies safe practice to rapid-acting insulin?
A. Hold the dose and notify the prescriber when clinically significant bradycardia or toxicity is suspected
B. Support ventilation and administer naloxone for clinically significant opioid-induced respiratory depression
C. Recheck glucose after treatment of hypoglycemia and identify the cause
D. Stop the infusion and prepare calcium gluconate when significant magnesium toxicity is suspected
Correct Answer: C. Recheck glucose after treatment of hypoglycemia and identify the cause
Rationale: Rapid-acting insulin has a quick onset; timing with meals and prompt treatment of hypoglycemia are
essential.
3. Which nursing intervention is most appropriate for delegation to assistive personnel?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Give clear directions, expected results, and specific findings that must be reported
C. Preserve relevant details and participate in nonpunitive analysis
D. Retain initial assessment, complex teaching, and rapidly changing clients for the RN
Correct Answer: B. Give clear directions, expected results, and specific findings that must be reported
Rationale: Delegation transfers performance of a task, not nursing accountability; unstable clients, assessment,
teaching, and evaluation remain RN responsibilities.
4. The plan of care addresses septic shock. Which action should the nurse include?
A. Repeat epinephrine and escalate airway/hemodynamic support when severe symptoms persist
B. Use norepinephrine as first-line vasopressor for persistent septic shock hypotension after appropriate fluids
C. Use manual elevation of the presenting part and appropriate maternal positioning while preparing operative
delivery
D. Prepare for reperfusion therapy when indicated and monitor for arrhythmia/shock
Correct Answer: B. Use norepinephrine as first-line vasopressor for persistent septic shock hypotension after
appropriate fluids
Rationale: Septic shock requires rapid infection treatment plus restoration of perfusion; norepinephrine is the
standard first-line vasopressor in most adults.
5. Which action by the nurse is most consistent with correct management of unfractionated heparin
infusion?
A. Stop heparin and follow protocol when serious bleeding or suspected HIT occurs
B. Hold the dose and notify the prescriber when clinically significant bradycardia or toxicity is suspected
C. Slow or stop the infusion and treat symptoms when an infusion reaction occurs, then resume per protocol if
appropriate
D. Hold/escalate therapy when significant nephrotoxicity or ototoxicity is suspected
Correct Answer: A. Stop heparin and follow protocol when serious bleeding or suspected HIT occurs
Rationale: Heparin therapy requires dose monitoring, bleeding assessment, and vigilance for heparin-induced
thrombocytopenia.
6. The plan of care addresses mass-casualty resource allocation. Which action should the nurse include?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Reassess triage categories because victim condition and resource availability change
C. Speak directly to the client and use plain language while the interpreter facilitates communication
D. Use case management, pharmacy, social work, or home health when needs cross disciplines
Correct Answer: B. Reassess triage categories because victim condition and resource availability change
,Rationale: Disaster triage differs from routine care because the goal is population-level benefit under constrained
resources.
7. Which nursing intervention is most appropriate for central-line infection prevention?
A. After convulsions stop, position for airway protection and assess breathing
B. Document the exposure circumstances and source information according to policy
C. Keep sterile items above waist level and within continuous view
D. Assess daily whether the central line is still necessary
Correct Answer: D. Assess daily whether the central line is still necessary
Rationale: CLABSI prevention combines insertion and maintenance bundles with daily necessity review.
8. Which action by the nurse is most consistent with correct management of end-of-life goals and hospice
referral?
A. Preserve relevant details and participate in nonpunitive analysis
B. Use case management, pharmacy, social work, or home health when needs cross disciplines
C. Coordinate symptom management and interdisciplinary support for the client and family
D. Ask about recent experience before finalizing the assignment
Correct Answer: C. Coordinate symptom management and interdisciplinary support for the client and family
Rationale: Goal-concordant care requires clear communication, respect for preferences, and appropriate
palliative/hospice support.
9. Which clinical decision best applies safe practice to acute ischemic stroke?
A. Use manual elevation of the presenting part and appropriate maternal positioning while preparing operative
delivery
B. Administer prescribed diuretic/vasodilator therapy and reassess respiratory response
C. Repeat epinephrine and escalate airway/hemodynamic support when severe symptoms persist
D. Maintain NPO status until swallow safety is assessed and follow ordered blood-pressure targets
Correct Answer: D. Maintain NPO status until swallow safety is assessed and follow ordered blood-pressure
targets
Rationale: Stroke outcomes depend on rapid imaging/reperfusion evaluation and prevention of secondary
complications.
10. Which nursing intervention is most appropriate for chain of command for unresolved safety concerns?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Give clear directions, expected results, and specific findings that must be reported
C. Confirm that the health care team has access to the most current directive
D. Ask about recent experience before finalizing the assignment
Correct Answer: A. State the concern clearly, cite objective findings, and document appropriate communication
Rationale: Nurses have a duty to advocate and escalate unresolved safety concerns using established channels.
11. Which action by the nurse is most consistent with correct management of oxytocin infusion?
A. Replace electrolytes or adjust therapy according to laboratory results and clinical status
B. Review interacting serotonergic drugs and monitor for serotonin toxicity
C. Hold the dose and notify the prescriber when clinically significant bradycardia or toxicity is suspected
D. Stop or reduce the infusion and begin intrauterine resuscitative measures for tachysystole with fetal
compromise
Correct Answer: D. Stop or reduce the infusion and begin intrauterine resuscitative measures for tachysystole
with fetal compromise
Rationale: Oxytocin requires close monitoring because excessive uterine activity can reduce uteroplacental
perfusion.
12. When caring for a client with near-miss reporting, which action is appropriate?
A. Preserve relevant details and participate in nonpunitive analysis
B. Document the client response and care provided without blaming language
C. Use case management, pharmacy, social work, or home health when needs cross disciplines
D. Protect screens, passwords, printouts, and verbal discussions from unauthorized viewing
Correct Answer: A. Preserve relevant details and participate in nonpunitive analysis
Rationale: Near-miss data support proactive safety improvement and learning.
13. Which intervention best reflects current nursing management of newborn safe sleep?
, A. Offer guideline-based vaccination and screening while respecting adolescent confidentiality laws
B. Use stair gates, window guards, and safe water practices appropriate to the home
C. Teach home blood-pressure technique when appropriate and review medication adherence
D. Reinforce safe sleep at every caregiver encounter
Correct Answer: D. Reinforce safe sleep at every caregiver encounter
Rationale: Safe-sleep practices reduce sleep-related infant deaths and avoid suffocation hazards.
14. When caring for a client with alcohol withdrawal, which action is appropriate?
A. Offer portable nutrient-dense foods and brief, concrete communication
B. Reduce environmental stimulation and monitor fluids, electrolytes, and autonomic signs
C. After symptoms decrease, explore triggers and coping strategies
D. Promote orientation, sleep, mobility, hydration, and sensory aids while treating the cause
Correct Answer: B. Reduce environmental stimulation and monitor fluids, electrolytes, and autonomic signs
Rationale: Withdrawal treatment prevents complications while supporting nutrition, hydration, and longer-term
recovery planning.
15. Which intervention best reflects current nursing management of seizure safety?
A. Assess daily whether the central line is still necessary
B. Use nonskid footwear and purposeful rounding rather than relying on restraints
C. After convulsions stop, position for airway protection and assess breathing
D. Limit transport and mask the client when transport is necessary
Correct Answer: C. After convulsions stop, position for airway protection and assess breathing
Rationale: Seizure safety focuses on preventing injury, maintaining airway/oxygenation, and observing the event
accurately.
16. The plan of care addresses assignment to an LPN/LVN. Which action should the nurse include?
A. State the concern clearly, cite objective findings, and document appropriate communication
B. Assess understanding, provide information, notify the provider, and document the informed refusal
C. Protect screens, passwords, printouts, and verbal discussions from unauthorized viewing
D. Retain initial assessment, complex teaching, and rapidly changing clients for the RN
Correct Answer: D. Retain initial assessment, complex teaching, and rapidly changing clients for the RN
Rationale: Assignment should match scope, competence, client stability, and predictability of outcomes.
17. When caring for a client with post-cardiac-catheterization bleeding, which action is appropriate?
A. Verify identity and blood-product information at the bedside before starting the product
B. Maintain ordered activity restrictions and monitor pulses, color, warmth, and bleeding
C. Use continuous cardiac monitoring during severe hyperkalemia treatment
D. Stop uterotonic stimulation and initiate appropriate intrauterine resuscitative measures when indicated
Correct Answer: B. Maintain ordered activity restrictions and monitor pulses, color, warmth, and bleeding
Rationale: Cardiac catheterization can cause access-site or retroperitoneal bleeding and limb ischemia, requiring
prompt recognition.
18. Which intervention best reflects current nursing management of diabetic ketoacidosis?
A. Use incentive spirometry during hospitalization for vaso-occlusive pain when appropriate to reduce pulmonary
complications
B. Delay insulin only when severe hypokalemia requires correction first, then continue protocolized treatment
C. Repeat epinephrine and escalate airway/hemodynamic support when severe symptoms persist
D. Assess for systemic inflammatory complications rather than using lipase value alone to judge severity
Correct Answer: B. Delay insulin only when severe hypokalemia requires correction first, then continue
protocolized treatment
Rationale: DKA treatment corrects dehydration and ketosis while carefully managing potassium and the
precipitating illness.
19. Which nursing intervention is most appropriate for phenytoin therapy?
A. Hold the dose and obtain urgent evaluation when toxicity is suspected
B. Hold and escalate promptly when angioedema is suspected
C. Review drug levels, interactions, and albumin status when toxicity or loss of control is suspected
D. Slow or stop the infusion and treat symptoms when an infusion reaction occurs, then resume per protocol if
appropriate
