HESI RN EXIT V2 SET 1 EXAM QUESTIONS
WITH ANSWERS AND EXPLANATIONS
1. A nurse discovers that a coworker appears impaired while providing client care. Which action is most
appropriate?
A. Protect clients and follow the facility procedure for reporting suspected impairment
B. Ignore the behavior unless a medication error occurs
C. Confront the coworker in front of clients
D. Post a warning about the coworker on the unit board
Correct Answer: A. Protect clients and follow the facility procedure for reporting suspected impairment
Rationale: Client safety is the priority. Suspected impairment should be addressed promptly through established
supervisory and reporting procedures.
2. A client begins receiving packed red blood cells and develops chills, fever, and low back pain 10 minutes
later. What should the nurse do first?
A. Slow the transfusion and reassess in 30 minutes
B. Discard the blood bag immediately before notifying anyone
C. Stop the transfusion and keep the IV line open with normal saline using new tubing
D. Administer acetaminophen and continue the transfusion
Correct Answer: C. Stop the transfusion and keep the IV line open with normal saline using new tubing
Rationale: These findings suggest an acute transfusion reaction. The transfusion is stopped immediately while IV
access is maintained with normal saline and the reaction protocol is initiated.
3. During disaster triage, which client should receive the highest priority for immediate treatment under
standard mass-casualty principles?
A. A walking client with superficial abrasions
B. A client with airway obstruction that can be rapidly corrected
C. A client with an open femur fracture and controlled bleeding who is alert
D. A pulseless client with massive head trauma
Correct Answer: B. A client with airway obstruction that can be rapidly corrected
Rationale: In mass-casualty triage, clients with life-threatening but rapidly treatable problems such as a
correctable airway obstruction receive immediate priority.
4. A client with acute asthma is using accessory muscles, has a respiratory rate of 34/min, and now has
markedly diminished breath sounds. How should the nurse interpret this change?
A. The client may have severely reduced airflow and impending respiratory failure
B. The bronchospasm is resolving
C. The client is developing fluid overload
D. This is an expected effect of albuterol
Correct Answer: A. The client may have severely reduced airflow and impending respiratory failure
Rationale: A "silent chest" or markedly diminished airflow in severe asthma is an ominous finding indicating
critical obstruction and possible respiratory failure.
5. Which task is appropriate for the RN to delegate to unlicensed assistive personnel (UAP)?
A. Obtain routine vital signs for a stable client
B. Assess a new pressure injury
C. Teach insulin self-injection
D. Evaluate pain relief after IV morphine
Correct Answer: A. Obtain routine vital signs for a stable client
Rationale: Routine data collection on a stable client can be delegated to UAP. Assessment, teaching, and
evaluation remain RN responsibilities.
6. Which assessment is most important before giving digoxin to an adult client?
A. Apical pulse for 1 full minute
B. Pupil response
C. Bowel sounds
D. Capillary refill in the toes
Correct Answer: A. Apical pulse for 1 full minute
,Rationale: Digoxin can slow AV conduction and heart rate; the apical pulse is assessed before administration,
and a low rate may require holding the dose.
7. A nurse sustains a needlestick from a used hollow-bore needle. Which action should be taken first?
A. Squeeze the wound vigorously for several minutes
B. Wait for symptoms before reporting
C. Apply bleach to the puncture site
D. Wash the area promptly with soap and water
Correct Answer: D. Wash the area promptly with soap and water
Rationale: Immediate washing is recommended after percutaneous exposure, followed by prompt reporting and
evaluation for postexposure management.
8. A competent adult refuses a recommended blood transfusion for religious reasons. Which action should
the nurse take?
A. Ask the family to authorize the transfusion
B. Document the refusal and notify the provider
C. Request an ethics order to override the refusal
D. Administer the transfusion because it is life-saving
Correct Answer: B. Document the refusal and notify the provider
Rationale: A competent adult has the right to refuse treatment. The nurse should respect the decision, ensure
informed refusal, document it, and notify the provider.
9. A client has a generalized tonic-clonic seizure in bed. Which nursing action is appropriate?
A. Insert a tongue blade between the teeth
B. Restrain the arms and legs
C. Turn the client to the side and protect the head
D. Offer water as soon as jerking begins
Correct Answer: C. Turn the client to the side and protect the head
Rationale: During a seizure, protect the client from injury, support the airway, and turn to the side when possible.
Do not insert objects into the mouth or restrain forcefully.
10. A nurse is asked by a provider to carry out an order that appears unsafe. What should the nurse do
first?
A. Carry out the order to avoid conflict
B. Clarify the order and use the chain of command if the safety concern remains unresolved
C. Ask a UAP to decide whether the order is safe
D. Document the concern but perform the order unchanged
Correct Answer: B. Clarify the order and use the chain of command if the safety concern remains unresolved
Rationale: Nurses are accountable for safe practice. An unclear or unsafe order should be questioned and
escalated through the chain of command if necessary.
11. A nurse is caring for a client with suspected Clostridioides difficile infection. Which action is most
appropriate?
A. Use alcohol-based hand rub after removing gloves
B. Place the client in a positive-pressure room
C. Wear an N95 respirator for all room entry
D. Wash hands with soap and water after care
Correct Answer: D. Wash hands with soap and water after care
Rationale: C. difficile spores are not reliably removed by alcohol-based hand rub. Contact precautions and
soap-and-water hand hygiene are appropriate.
12. A client receiving IV unfractionated heparin has an aPTT far above the prescribed therapeutic range
and oozing from the IV site. What should the nurse do first?
A. Administer vitamin K
B. Increase the infusion rate
C. Give aspirin for clot prevention
D. Stop the heparin infusion
Correct Answer: D. Stop the heparin infusion
Rationale: Excess anticoagulation with active bleeding requires stopping heparin and notifying the provider;
protamine sulfate may be prescribed. Vitamin K reverses warfarin, not heparin.
, 13. A client with sickle cell disease presents with severe generalized pain and oxygen saturation 97% on
room air. Which intervention is a priority?
A. Restrict fluids to prevent edema
B. Apply ice packs to painful joints
C. Delay pain treatment until imaging is completed
D. Begin prescribed analgesia and hydration promptly while assessing for complications
Correct Answer: D. Begin prescribed analgesia and hydration promptly while assessing for complications
Rationale: Vaso-occlusive pain crisis is treated promptly with analgesia and hydration while monitoring for
serious complications. Cold exposure can worsen vasoconstriction.
14. A client with neutropenia after chemotherapy is admitted. Which action should the nurse prioritize?
A. Place fresh flowers in the room
B. Serve raw sprouts with meals
C. Screen visitors for illness and emphasize hand hygiene
D. Use rectal temperatures for accuracy
Correct Answer: C. Screen visitors for illness and emphasize hand hygiene
Rationale: Neutropenic clients need infection-risk reduction, especially hand hygiene and avoidance of ill
contacts. Raw foods, flowers/plants, and rectal procedures may increase infection risk.
15. A client with sepsis remains hypotensive after an initial fluid bolus and has lactate 5.1 mmol/L. Which
therapy should the nurse anticipate next?
A. Fluid restriction
B. Routine oral antihypertensive medication
C. Delayed antibiotics until culture results return
D. Vasopressor support
Correct Answer: D. Vasopressor support
Rationale: Persistent hypotension after adequate fluid resuscitation suggests septic shock and may require
vasopressors while antibiotics and source control continue.
16. A client asks to leave the hospital against medical advice. Which nursing action is appropriate?
A. Physically prevent departure
B. Tell the client insurance will never pay
C. Explain foreseeable risks, notify the provider, and document the discussion
D. Remove the client’s belongings
Correct Answer: C. Explain foreseeable risks, notify the provider, and document the discussion
Rationale: Competent clients may leave against medical advice. The nurse should provide risk information,
attempt safe planning, notify the provider, and document.
17. A client receives regular insulin IV for hyperkalemia. Which additional medication is commonly given
at the same time to prevent hypoglycemia?
A. Calcium carbonate by mouth
B. Dextrose
C. Vitamin K
D. Magnesium sulfate
Correct Answer: B. Dextrose
Rationale: Insulin shifts potassium into cells but also lowers glucose; IV dextrose is commonly given unless
hyperglycemia is sufficient to make it unnecessary.
18. A client taking an ACE inhibitor develops swelling of the lips and tongue. What should the nurse do
first?
A. Document the expected adverse effect
B. Offer ice chips and reassess tomorrow
C. Administer the next dose with food
D. Treat this as an airway emergency and stop the medication
Correct Answer: D. Treat this as an airway emergency and stop the medication
Rationale: Angioedema can rapidly compromise the airway and is a serious ACE-inhibitor adverse effect
requiring emergency management and discontinuation.
19. A client with chronic kidney disease has potassium 6.7 mEq/L and peaked T waves. Which intervention
has the highest immediate priority?
WITH ANSWERS AND EXPLANATIONS
1. A nurse discovers that a coworker appears impaired while providing client care. Which action is most
appropriate?
A. Protect clients and follow the facility procedure for reporting suspected impairment
B. Ignore the behavior unless a medication error occurs
C. Confront the coworker in front of clients
D. Post a warning about the coworker on the unit board
Correct Answer: A. Protect clients and follow the facility procedure for reporting suspected impairment
Rationale: Client safety is the priority. Suspected impairment should be addressed promptly through established
supervisory and reporting procedures.
2. A client begins receiving packed red blood cells and develops chills, fever, and low back pain 10 minutes
later. What should the nurse do first?
A. Slow the transfusion and reassess in 30 minutes
B. Discard the blood bag immediately before notifying anyone
C. Stop the transfusion and keep the IV line open with normal saline using new tubing
D. Administer acetaminophen and continue the transfusion
Correct Answer: C. Stop the transfusion and keep the IV line open with normal saline using new tubing
Rationale: These findings suggest an acute transfusion reaction. The transfusion is stopped immediately while IV
access is maintained with normal saline and the reaction protocol is initiated.
3. During disaster triage, which client should receive the highest priority for immediate treatment under
standard mass-casualty principles?
A. A walking client with superficial abrasions
B. A client with airway obstruction that can be rapidly corrected
C. A client with an open femur fracture and controlled bleeding who is alert
D. A pulseless client with massive head trauma
Correct Answer: B. A client with airway obstruction that can be rapidly corrected
Rationale: In mass-casualty triage, clients with life-threatening but rapidly treatable problems such as a
correctable airway obstruction receive immediate priority.
4. A client with acute asthma is using accessory muscles, has a respiratory rate of 34/min, and now has
markedly diminished breath sounds. How should the nurse interpret this change?
A. The client may have severely reduced airflow and impending respiratory failure
B. The bronchospasm is resolving
C. The client is developing fluid overload
D. This is an expected effect of albuterol
Correct Answer: A. The client may have severely reduced airflow and impending respiratory failure
Rationale: A "silent chest" or markedly diminished airflow in severe asthma is an ominous finding indicating
critical obstruction and possible respiratory failure.
5. Which task is appropriate for the RN to delegate to unlicensed assistive personnel (UAP)?
A. Obtain routine vital signs for a stable client
B. Assess a new pressure injury
C. Teach insulin self-injection
D. Evaluate pain relief after IV morphine
Correct Answer: A. Obtain routine vital signs for a stable client
Rationale: Routine data collection on a stable client can be delegated to UAP. Assessment, teaching, and
evaluation remain RN responsibilities.
6. Which assessment is most important before giving digoxin to an adult client?
A. Apical pulse for 1 full minute
B. Pupil response
C. Bowel sounds
D. Capillary refill in the toes
Correct Answer: A. Apical pulse for 1 full minute
,Rationale: Digoxin can slow AV conduction and heart rate; the apical pulse is assessed before administration,
and a low rate may require holding the dose.
7. A nurse sustains a needlestick from a used hollow-bore needle. Which action should be taken first?
A. Squeeze the wound vigorously for several minutes
B. Wait for symptoms before reporting
C. Apply bleach to the puncture site
D. Wash the area promptly with soap and water
Correct Answer: D. Wash the area promptly with soap and water
Rationale: Immediate washing is recommended after percutaneous exposure, followed by prompt reporting and
evaluation for postexposure management.
8. A competent adult refuses a recommended blood transfusion for religious reasons. Which action should
the nurse take?
A. Ask the family to authorize the transfusion
B. Document the refusal and notify the provider
C. Request an ethics order to override the refusal
D. Administer the transfusion because it is life-saving
Correct Answer: B. Document the refusal and notify the provider
Rationale: A competent adult has the right to refuse treatment. The nurse should respect the decision, ensure
informed refusal, document it, and notify the provider.
9. A client has a generalized tonic-clonic seizure in bed. Which nursing action is appropriate?
A. Insert a tongue blade between the teeth
B. Restrain the arms and legs
C. Turn the client to the side and protect the head
D. Offer water as soon as jerking begins
Correct Answer: C. Turn the client to the side and protect the head
Rationale: During a seizure, protect the client from injury, support the airway, and turn to the side when possible.
Do not insert objects into the mouth or restrain forcefully.
10. A nurse is asked by a provider to carry out an order that appears unsafe. What should the nurse do
first?
A. Carry out the order to avoid conflict
B. Clarify the order and use the chain of command if the safety concern remains unresolved
C. Ask a UAP to decide whether the order is safe
D. Document the concern but perform the order unchanged
Correct Answer: B. Clarify the order and use the chain of command if the safety concern remains unresolved
Rationale: Nurses are accountable for safe practice. An unclear or unsafe order should be questioned and
escalated through the chain of command if necessary.
11. A nurse is caring for a client with suspected Clostridioides difficile infection. Which action is most
appropriate?
A. Use alcohol-based hand rub after removing gloves
B. Place the client in a positive-pressure room
C. Wear an N95 respirator for all room entry
D. Wash hands with soap and water after care
Correct Answer: D. Wash hands with soap and water after care
Rationale: C. difficile spores are not reliably removed by alcohol-based hand rub. Contact precautions and
soap-and-water hand hygiene are appropriate.
12. A client receiving IV unfractionated heparin has an aPTT far above the prescribed therapeutic range
and oozing from the IV site. What should the nurse do first?
A. Administer vitamin K
B. Increase the infusion rate
C. Give aspirin for clot prevention
D. Stop the heparin infusion
Correct Answer: D. Stop the heparin infusion
Rationale: Excess anticoagulation with active bleeding requires stopping heparin and notifying the provider;
protamine sulfate may be prescribed. Vitamin K reverses warfarin, not heparin.
, 13. A client with sickle cell disease presents with severe generalized pain and oxygen saturation 97% on
room air. Which intervention is a priority?
A. Restrict fluids to prevent edema
B. Apply ice packs to painful joints
C. Delay pain treatment until imaging is completed
D. Begin prescribed analgesia and hydration promptly while assessing for complications
Correct Answer: D. Begin prescribed analgesia and hydration promptly while assessing for complications
Rationale: Vaso-occlusive pain crisis is treated promptly with analgesia and hydration while monitoring for
serious complications. Cold exposure can worsen vasoconstriction.
14. A client with neutropenia after chemotherapy is admitted. Which action should the nurse prioritize?
A. Place fresh flowers in the room
B. Serve raw sprouts with meals
C. Screen visitors for illness and emphasize hand hygiene
D. Use rectal temperatures for accuracy
Correct Answer: C. Screen visitors for illness and emphasize hand hygiene
Rationale: Neutropenic clients need infection-risk reduction, especially hand hygiene and avoidance of ill
contacts. Raw foods, flowers/plants, and rectal procedures may increase infection risk.
15. A client with sepsis remains hypotensive after an initial fluid bolus and has lactate 5.1 mmol/L. Which
therapy should the nurse anticipate next?
A. Fluid restriction
B. Routine oral antihypertensive medication
C. Delayed antibiotics until culture results return
D. Vasopressor support
Correct Answer: D. Vasopressor support
Rationale: Persistent hypotension after adequate fluid resuscitation suggests septic shock and may require
vasopressors while antibiotics and source control continue.
16. A client asks to leave the hospital against medical advice. Which nursing action is appropriate?
A. Physically prevent departure
B. Tell the client insurance will never pay
C. Explain foreseeable risks, notify the provider, and document the discussion
D. Remove the client’s belongings
Correct Answer: C. Explain foreseeable risks, notify the provider, and document the discussion
Rationale: Competent clients may leave against medical advice. The nurse should provide risk information,
attempt safe planning, notify the provider, and document.
17. A client receives regular insulin IV for hyperkalemia. Which additional medication is commonly given
at the same time to prevent hypoglycemia?
A. Calcium carbonate by mouth
B. Dextrose
C. Vitamin K
D. Magnesium sulfate
Correct Answer: B. Dextrose
Rationale: Insulin shifts potassium into cells but also lowers glucose; IV dextrose is commonly given unless
hyperglycemia is sufficient to make it unnecessary.
18. A client taking an ACE inhibitor develops swelling of the lips and tongue. What should the nurse do
first?
A. Document the expected adverse effect
B. Offer ice chips and reassess tomorrow
C. Administer the next dose with food
D. Treat this as an airway emergency and stop the medication
Correct Answer: D. Treat this as an airway emergency and stop the medication
Rationale: Angioedema can rapidly compromise the airway and is a serious ACE-inhibitor adverse effect
requiring emergency management and discontinuation.
19. A client with chronic kidney disease has potassium 6.7 mEq/L and peaked T waves. Which intervention
has the highest immediate priority?
