HESI RN EXIT V1 SET 1 NGN QUESTIONS
WITH ANSWERS AND EXPLANATIONS
Question 1.
A change in status suggests School-age health promotion: school-age children develop
competence through school peers hobbies and increasing responsibility. Which action
should the nurse implement before routine care continues?
A. Encourage participation in school activities physical activity and age-appropriate
self-care.
B. Assist with repositioning and relatching when feeding is painful or shallow.
C. Lock medications cleaners firearms and small choking hazards out of reach.
D. Teach caregivers to place the infant on the back for every sleep.
Correct Answer: A. Encourage participation in school activities physical activity
and age-appropriate self-care.
Explanation: This answer is the best match for the client data and the expected nursing
standard. For School-age health promotion, the priority intervention is encourage
participation in school activities physical activity and age-appropriate self-care.
Health-promotion care emphasizes prevention, development, screening, immunization,
anticipatory guidance, and early recognition of warning signs. The other choices may be
reasonable in different clinical contexts, but they do not address the stated problem as
directly or safely; after the intervention, the nurse should reassess the relevant
physiologic, safety, or behavioral response and escalate care if the expected improvement
does not occur.
Question 2.
The nurse identifies findings consistent with Palliative care: palliative care can be provided
alongside disease-directed treatment at any stage of serious illness. What is the priority
nursing response?
A. The RN assumes care of the client with new respiratory distress.
B. Request palliative support for burdensome symptoms and complex goals-of-care needs.
C. Assign the routine dressing change while the RN manages new or unstable problems.
D. Verify the surrogate's authority when the client lacks capacity.
Correct Answer: B. Request palliative support for burdensome symptoms and
complex goals-of-care needs.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. For Palliative care, the priority intervention is
request palliative support for burdensome symptoms and complex goals-of-care needs.
Management decisions must account for acuity, scope of practice, client rights,
communication, continuity, and RN accountability. The other choices may be reasonable in
different clinical contexts, but they do not address the stated problem as directly or safely;
after the intervention, the nurse should reassess the relevant physiologic, safety, or
behavioral response and escalate care if the expected improvement does not occur.
,Question 3.
The care team is managing Airborne precautions for pulmonary tuberculosis after the
nurse recognizes suspected infectious pulmonary tuberculosis requires airborne isolation.
Which nursing intervention has the highest priority?
A. Use gloves and other PPE based on anticipated exposure for every client.
B. Use a negative-pressure room and respirator according to facility policy.
C. Place the client in a negative-pressure room and use a fit-tested respirator.
D. Wear a surgical mask for close contact and follow droplet isolation policy.
Correct Answer: C. Place the client in a negative-pressure room and use a
fit-tested respirator.
Explanation: The selected response is the most appropriate next step for the situation
presented. For Airborne precautions for pulmonary tuberculosis, the priority intervention is
place the client in a negative-pressure room and use a fit-tested respirator. Safety
decisions should interrupt exposure or injury risk while preserving appropriate
infection-control and surveillance measures. The other choices may be reasonable in
different clinical contexts, but they do not address the stated problem as directly or safely;
after the intervention, the nurse should reassess the relevant physiologic, safety, or
behavioral response and escalate care if the expected improvement does not occur.
Question 4.
A change in status suggests Delirium: delirium has acute fluctuating inattention and
altered cognition and often reflects a medical cause. Which action should the nurse
implement before routine care continues?
A. Use calm communication help identify manageable concerns and support
evidence-based therapy.
B. Focus on feelings and reality-based needs rather than arguing about the belief.
C. Set small concrete goals for self-care activity and social engagement.
D. Identify and treat the underlying cause while providing safety orientation and sleep
support.
Correct Answer: D. Identify and treat the underlying cause while providing
safety orientation and sleep support.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. For Delirium, the priority intervention is identify
and treat the underlying cause while providing safety orientation and sleep support.
Psychosocial nursing prioritizes immediate safety, therapeutic communication, dignity,
boundaries, recovery, and the least restrictive effective approach. The other choices may
be reasonable in different clinical contexts, but they do not address the stated problem as
directly or safely; after the intervention, the nurse should reassess the relevant
physiologic, safety, or behavioral response and escalate care if the expected improvement
does not occur.
,Question 5.
During care on a rehabilitation unit, a client presents with stable clients with predictable
outcomes may receive routine medications from an LPN according to scope. Which nursing
action should occur first?
A. Assign scheduled oral medications for a stable client to the LPN.
B. The RN assumes care of the client with new respiratory distress.
C. Assign the routine dressing change while the RN manages new or unstable problems.
D. Assign routine vital signs to UAP and have abnormal values reported promptly.
Correct Answer: A. Assign scheduled oral medications for a stable client to the
LPN.
Explanation: The correct option most specifically addresses the safety or physiologic
issue described. For Assignment to an LPN of routine medications, the priority intervention
is assign scheduled oral medications for a stable client to the LPN. Management decisions
must account for acuity, scope of practice, client rights, communication, continuity, and
RN accountability. The other choices may be reasonable in different clinical contexts, but
they do not address the stated problem as directly or safely; after the intervention, the
nurse should reassess the relevant physiologic, safety, or behavioral response and
escalate care if the expected improvement does not occur.
Question 6.
During care on an intensive-care step-down unit, a client presents with a seizure lasting
several minutes or repeated seizures without recovery is a neurologic emergency. Which
nursing action should occur first?
A. Identify precipitants and give lactulose or other prescribed therapy to reduce intestinal
nitrogen load.
B. Stabilize blood pressure prevent seizures with magnesium as ordered and plan delivery
based on maternal-fetal status.
C. Protect the airway provide oxygen and give rapid-acting anticonvulsant therapy as
ordered.
D. Protect the airway position laterally give magnesium as ordered and stabilize maternal
and fetal status.
Correct Answer: C. Protect the airway provide oxygen and give rapid-acting
anticonvulsant therapy as ordered.
Explanation: This choice best fits the cue pattern and the nursing priority being tested.
For Status epilepticus, the priority intervention is protect the airway provide oxygen and
give rapid-acting anticonvulsant therapy as ordered. Physiological priorities protect
airway, breathing, circulation, perfusion, neurologic function, and organ stability while
definitive treatment proceeds. The other choices may be reasonable in different clinical
contexts, but they do not address the stated problem as directly or safely; after the
intervention, the nurse should reassess the relevant physiologic, safety, or behavioral
response and escalate care if the expected improvement does not occur.
, Question 7.
A 76-year-old client on an emergency department develops an incident report supports
risk management and quality improvement and is not part of the medical record. Which
intervention best addresses the immediate problem?
A. Write the order read it back and clarify any discrepancy before acting.
B. Decline an assignment that requires an intervention outside the nurse's authorized
scope and escalate appropriately.
C. Ensure immediate safety and make the required report when there is reasonable
suspicion.
D. Provide client care first then complete the institutional incident report.
Correct Answer: D. Provide client care first then complete the institutional
incident report.
Explanation: This answer is the best match for the client data and the expected nursing
standard. For Incident reporting, the priority intervention is provide client care first then
complete the institutional incident report. Management decisions must account for acuity,
scope of practice, client rights, communication, continuity, and RN accountability. The
other choices may be reasonable in different clinical contexts, but they do not address the
stated problem as directly or safely; after the intervention, the nurse should reassess the
relevant physiologic, safety, or behavioral response and escalate care if the expected
improvement does not occur.
Question 8.
During care on a maternal-newborn unit, a client presents with low-molecular-weight
heparin is given subcutaneously and can cause bleeding and thrombocytopenia. Which
nursing action should occur first?
A. Treat acute dystonia promptly with the prescribed anticholinergic or antihistamine and
assess the airway.
B. Inject into abdominal subcutaneous tissue and avoid expelling the manufacturer air
bubble when instructed for prefilled syringes.
C. Administer at recommended antepartum or postpartum and bleeding-event times when
criteria are met.
D. Use the lowest effective dose and stop or seek care for GI bleeding or acute kidney
injury signs.
Correct Answer: B. Inject into abdominal subcutaneous tissue and avoid
expelling the manufacturer air bubble when instructed for prefilled syringes.
Explanation: This choice best fits the cue pattern and the nursing priority being tested.
For Enoxaparin, the priority intervention is inject into abdominal subcutaneous tissue and
avoid expelling the manufacturer air bubble when instructed for prefilled syringes.
Medication decisions require attention to indication, dose, administration safety, adverse
effects, interactions, and response to therapy. The other choices may be reasonable in
different clinical contexts, but they do not address the stated problem as directly or safely;
after the intervention, the nurse should reassess the relevant physiologic, safety, or
behavioral response and escalate care if the expected improvement does not occur.
WITH ANSWERS AND EXPLANATIONS
Question 1.
A change in status suggests School-age health promotion: school-age children develop
competence through school peers hobbies and increasing responsibility. Which action
should the nurse implement before routine care continues?
A. Encourage participation in school activities physical activity and age-appropriate
self-care.
B. Assist with repositioning and relatching when feeding is painful or shallow.
C. Lock medications cleaners firearms and small choking hazards out of reach.
D. Teach caregivers to place the infant on the back for every sleep.
Correct Answer: A. Encourage participation in school activities physical activity
and age-appropriate self-care.
Explanation: This answer is the best match for the client data and the expected nursing
standard. For School-age health promotion, the priority intervention is encourage
participation in school activities physical activity and age-appropriate self-care.
Health-promotion care emphasizes prevention, development, screening, immunization,
anticipatory guidance, and early recognition of warning signs. The other choices may be
reasonable in different clinical contexts, but they do not address the stated problem as
directly or safely; after the intervention, the nurse should reassess the relevant
physiologic, safety, or behavioral response and escalate care if the expected improvement
does not occur.
Question 2.
The nurse identifies findings consistent with Palliative care: palliative care can be provided
alongside disease-directed treatment at any stage of serious illness. What is the priority
nursing response?
A. The RN assumes care of the client with new respiratory distress.
B. Request palliative support for burdensome symptoms and complex goals-of-care needs.
C. Assign the routine dressing change while the RN manages new or unstable problems.
D. Verify the surrogate's authority when the client lacks capacity.
Correct Answer: B. Request palliative support for burdensome symptoms and
complex goals-of-care needs.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. For Palliative care, the priority intervention is
request palliative support for burdensome symptoms and complex goals-of-care needs.
Management decisions must account for acuity, scope of practice, client rights,
communication, continuity, and RN accountability. The other choices may be reasonable in
different clinical contexts, but they do not address the stated problem as directly or safely;
after the intervention, the nurse should reassess the relevant physiologic, safety, or
behavioral response and escalate care if the expected improvement does not occur.
,Question 3.
The care team is managing Airborne precautions for pulmonary tuberculosis after the
nurse recognizes suspected infectious pulmonary tuberculosis requires airborne isolation.
Which nursing intervention has the highest priority?
A. Use gloves and other PPE based on anticipated exposure for every client.
B. Use a negative-pressure room and respirator according to facility policy.
C. Place the client in a negative-pressure room and use a fit-tested respirator.
D. Wear a surgical mask for close contact and follow droplet isolation policy.
Correct Answer: C. Place the client in a negative-pressure room and use a
fit-tested respirator.
Explanation: The selected response is the most appropriate next step for the situation
presented. For Airborne precautions for pulmonary tuberculosis, the priority intervention is
place the client in a negative-pressure room and use a fit-tested respirator. Safety
decisions should interrupt exposure or injury risk while preserving appropriate
infection-control and surveillance measures. The other choices may be reasonable in
different clinical contexts, but they do not address the stated problem as directly or safely;
after the intervention, the nurse should reassess the relevant physiologic, safety, or
behavioral response and escalate care if the expected improvement does not occur.
Question 4.
A change in status suggests Delirium: delirium has acute fluctuating inattention and
altered cognition and often reflects a medical cause. Which action should the nurse
implement before routine care continues?
A. Use calm communication help identify manageable concerns and support
evidence-based therapy.
B. Focus on feelings and reality-based needs rather than arguing about the belief.
C. Set small concrete goals for self-care activity and social engagement.
D. Identify and treat the underlying cause while providing safety orientation and sleep
support.
Correct Answer: D. Identify and treat the underlying cause while providing
safety orientation and sleep support.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. For Delirium, the priority intervention is identify
and treat the underlying cause while providing safety orientation and sleep support.
Psychosocial nursing prioritizes immediate safety, therapeutic communication, dignity,
boundaries, recovery, and the least restrictive effective approach. The other choices may
be reasonable in different clinical contexts, but they do not address the stated problem as
directly or safely; after the intervention, the nurse should reassess the relevant
physiologic, safety, or behavioral response and escalate care if the expected improvement
does not occur.
,Question 5.
During care on a rehabilitation unit, a client presents with stable clients with predictable
outcomes may receive routine medications from an LPN according to scope. Which nursing
action should occur first?
A. Assign scheduled oral medications for a stable client to the LPN.
B. The RN assumes care of the client with new respiratory distress.
C. Assign the routine dressing change while the RN manages new or unstable problems.
D. Assign routine vital signs to UAP and have abnormal values reported promptly.
Correct Answer: A. Assign scheduled oral medications for a stable client to the
LPN.
Explanation: The correct option most specifically addresses the safety or physiologic
issue described. For Assignment to an LPN of routine medications, the priority intervention
is assign scheduled oral medications for a stable client to the LPN. Management decisions
must account for acuity, scope of practice, client rights, communication, continuity, and
RN accountability. The other choices may be reasonable in different clinical contexts, but
they do not address the stated problem as directly or safely; after the intervention, the
nurse should reassess the relevant physiologic, safety, or behavioral response and
escalate care if the expected improvement does not occur.
Question 6.
During care on an intensive-care step-down unit, a client presents with a seizure lasting
several minutes or repeated seizures without recovery is a neurologic emergency. Which
nursing action should occur first?
A. Identify precipitants and give lactulose or other prescribed therapy to reduce intestinal
nitrogen load.
B. Stabilize blood pressure prevent seizures with magnesium as ordered and plan delivery
based on maternal-fetal status.
C. Protect the airway provide oxygen and give rapid-acting anticonvulsant therapy as
ordered.
D. Protect the airway position laterally give magnesium as ordered and stabilize maternal
and fetal status.
Correct Answer: C. Protect the airway provide oxygen and give rapid-acting
anticonvulsant therapy as ordered.
Explanation: This choice best fits the cue pattern and the nursing priority being tested.
For Status epilepticus, the priority intervention is protect the airway provide oxygen and
give rapid-acting anticonvulsant therapy as ordered. Physiological priorities protect
airway, breathing, circulation, perfusion, neurologic function, and organ stability while
definitive treatment proceeds. The other choices may be reasonable in different clinical
contexts, but they do not address the stated problem as directly or safely; after the
intervention, the nurse should reassess the relevant physiologic, safety, or behavioral
response and escalate care if the expected improvement does not occur.
, Question 7.
A 76-year-old client on an emergency department develops an incident report supports
risk management and quality improvement and is not part of the medical record. Which
intervention best addresses the immediate problem?
A. Write the order read it back and clarify any discrepancy before acting.
B. Decline an assignment that requires an intervention outside the nurse's authorized
scope and escalate appropriately.
C. Ensure immediate safety and make the required report when there is reasonable
suspicion.
D. Provide client care first then complete the institutional incident report.
Correct Answer: D. Provide client care first then complete the institutional
incident report.
Explanation: This answer is the best match for the client data and the expected nursing
standard. For Incident reporting, the priority intervention is provide client care first then
complete the institutional incident report. Management decisions must account for acuity,
scope of practice, client rights, communication, continuity, and RN accountability. The
other choices may be reasonable in different clinical contexts, but they do not address the
stated problem as directly or safely; after the intervention, the nurse should reassess the
relevant physiologic, safety, or behavioral response and escalate care if the expected
improvement does not occur.
Question 8.
During care on a maternal-newborn unit, a client presents with low-molecular-weight
heparin is given subcutaneously and can cause bleeding and thrombocytopenia. Which
nursing action should occur first?
A. Treat acute dystonia promptly with the prescribed anticholinergic or antihistamine and
assess the airway.
B. Inject into abdominal subcutaneous tissue and avoid expelling the manufacturer air
bubble when instructed for prefilled syringes.
C. Administer at recommended antepartum or postpartum and bleeding-event times when
criteria are met.
D. Use the lowest effective dose and stop or seek care for GI bleeding or acute kidney
injury signs.
Correct Answer: B. Inject into abdominal subcutaneous tissue and avoid
expelling the manufacturer air bubble when instructed for prefilled syringes.
Explanation: This choice best fits the cue pattern and the nursing priority being tested.
For Enoxaparin, the priority intervention is inject into abdominal subcutaneous tissue and
avoid expelling the manufacturer air bubble when instructed for prefilled syringes.
Medication decisions require attention to indication, dose, administration safety, adverse
effects, interactions, and response to therapy. The other choices may be reasonable in
different clinical contexts, but they do not address the stated problem as directly or safely;
after the intervention, the nurse should reassess the relevant physiologic, safety, or
behavioral response and escalate care if the expected improvement does not occur.
