HESI RN EXIT V2 SET 3 EXAM QUESTIONS
WITH ANSWERS AND EXPLANATIONS
1. A nurse observes a provider entering a procedure room without performing required hand hygiene.
What should the nurse do?
A. Ignore it because the provider is senior
B. Document it only after the procedure without intervening
C. Ask the client to confront the provider
D. Speak up promptly to protect the client and reinforce the safety standard
Correct Answer: D. Speak up promptly to protect the client and reinforce the safety standard
Rationale: Safety culture supports respectful real-time intervention when a preventable infection-control breach
is observed.
2. A client receiving continuous enteral nutrition is prescribed phenytoin. What should the nurse
recognize?
A. Phenytoin must always be mixed into the formula bag
B. Drug levels are never needed
C. Enteral feeding can reduce phenytoin absorption, so administration and levels may need coordination
D. Enteral feeding doubles phenytoin absorption predictably
Correct Answer: C. Enteral feeding can reduce phenytoin absorption, so administration and levels may need
coordination
Rationale: Phenytoin absorption can be reduced by enteral feeds; timing and therapeutic monitoring should
follow pharmacy/provider guidance.
3. A client wants to designate a surrogate decision-maker. Which document is most directly used for this
purpose?
A. Medication administration record
B. Durable power of attorney for health care/health-care proxy according to local law
C. Incident report
D. Staff assignment sheet
Correct Answer: B. Durable power of attorney for health care/health-care proxy according to local law
Rationale: A health-care proxy or durable power of attorney for health care designates a surrogate to make health
decisions when the client cannot.
4. A client with suspected C. difficile diarrhea needs a portable commode. What is the best equipment
practice?
A. Share it between clients without cleaning
B. Dedicate the commode to the client and disinfect it with an effective sporicidal process
C. Clean it only with plain water once weekly
D. Store it in the hallway after use
Correct Answer: B. Dedicate the commode to the client and disinfect it with an effective sporicidal process
Rationale: C. difficile spores persist in the environment, so dedicated equipment and effective sporicidal cleaning
are important.
5. A client prescribed levodopa/carbidopa asks about stopping the drug suddenly. Which response is best?
A. Stop whenever symptoms improve
B. Do not stop abruptly without prescriber guidance because severe worsening can occur
C. Double the dose after missed doses
D. Take only on days with tremor
Correct Answer: B. Do not stop abruptly without prescriber guidance because severe worsening can occur
Rationale: Abrupt withdrawal can cause severe rigidity, immobility, or neuroleptic-malignant-like syndromes;
therapy should be adjusted with guidance.
6. The RN delegates ambulation of a stable client to UAP. Which statement reflects proper delegation?
A. The UAP assumes full nursing accountability
B. No follow-up is needed
C. The RN remains accountable for evaluating the outcome
D. The RN may delegate assessment and nursing diagnosis at the same time
,Correct Answer: C. The RN remains accountable for evaluating the outcome
Rationale: Delegation transfers performance of a task, not RN accountability for assessment, supervision, and
evaluation.
7. A client has a draining wound infected with multidrug-resistant organism. Which equipment practice is
best?
A. Dedicate noncritical equipment to the client or disinfect it before reuse
B. Share the same blood pressure cuff without cleaning
C. Store contaminated supplies in the hallway
D. Reuse disposable gloves
Correct Answer: A. Dedicate noncritical equipment to the client or disinfect it before reuse
Rationale: Dedicated or properly disinfected equipment reduces contact transmission.
8. A client with pulmonary embolism becomes suddenly hypotensive and syncopal. Which complication is
most likely?
A. Mild bronchitis
B. Stable chronic venous insufficiency
C. Simple anxiety
D. Massive PE with obstructive shock
Correct Answer: D. Massive PE with obstructive shock
Rationale: Sudden hypotension/syncope in PE suggests major obstruction of pulmonary circulation and
right-heart failure.
9. A client on long-term corticosteroids develops fever and cough. Why should the nurse take these
symptoms seriously?
A. Corticosteroids prevent all infections
B. Fever cannot occur while taking steroids
C. Corticosteroids can suppress immune responses and mask infection severity
D. Cough is always medication withdrawal
Correct Answer: C. Corticosteroids can suppress immune responses and mask infection severity
Rationale: Chronic corticosteroids increase infection risk and can blunt inflammatory signs, so new symptoms
warrant evaluation.
10. Which situation requires the nurse to use the chain of command?
A. A client requests a different breakfast item
B. A provider does not respond to repeated reports of a rapidly deteriorating client
C. A family asks visiting hours
D. A stable client wants a blanket
Correct Answer: B. A provider does not respond to repeated reports of a rapidly deteriorating client
Rationale: When a serious safety concern remains unresolved, escalation through the chain of command is
appropriate.
11. A client with chest trauma suddenly becomes hypotensive with distended neck veins and muffled heart
sounds. Which condition should the nurse suspect?
A. Left-sided heart failure
B. Simple rib fracture
C. Cardiac tamponade
D. Pulmonary fibrosis
Correct Answer: C. Cardiac tamponade
Rationale: Hypotension, JVD, and muffled heart sounds are classic findings of cardiac tamponade and
obstructive shock.
12. A client with seizure disorder is admitted. Which room setup is safest?
A. Padded tongue blade at bedside for insertion
B. Four side rails raised with restraints tied to them
C. Room farthest from staff without call bell
D. Bed low, suction and oxygen available, and seizure precautions in place
Correct Answer: D. Bed low, suction and oxygen available, and seizure precautions in place
Rationale: Seizure precautions emphasize injury prevention and airway support; objects should not be placed in
the mouth.
, 13. A client on clozapine reports fever and sore throat. Which action is most important?
A. Give the next dose early
B. Assume this is seasonal allergy
C. Obtain urgent evaluation of the absolute neutrophil count
D. Start a live vaccine
Correct Answer: C. Obtain urgent evaluation of the absolute neutrophil count
Rationale: Clozapine can cause severe neutropenia; infection symptoms require prompt blood count assessment
and
medication guidance.
14. A client with limited health literacy is learning a complex medication schedule. Which teaching method
is best?
A. Provide only a dense technical handout
B. Ask, "Do you understand?" and end teaching after yes
C. Use plain language and teach-back in small chunks
D. Use unexplained abbreviations
Correct Answer: C. Use plain language and teach-back in small chunks
Rationale: Plain language, chunking, and teach-back better assess and support comprehension than yes/no
questions.
15. A client with SIADH has sodium 116 mEq/L, headache, and confusion. Which nursing action is
priority?
A. Encourage unrestricted free water intake
B. Administer hypotonic IV fluid rapidly
C. Provide a high-potassium diet only
D. Institute seizure precautions and manage severe hyponatremia as prescribed
Correct Answer: D. Institute seizure precautions and manage severe hyponatremia as prescribed
Rationale: Severe symptomatic hyponatremia can cause seizures and cerebral edema; safety and controlled
correction are priorities.
16. A client with disseminated herpes zoster is admitted. Which precautions are appropriate?
A. Droplet precautions only
B. Standard precautions only
C. Protective isolation only
D. Airborne and contact precautions
Correct Answer: D. Airborne and contact precautions
Rationale: Disseminated zoster requires airborne and contact precautions until lesions are appropriately managed
and no longer infectious.
17. A client with severe hyperkalemia has widened QRS complexes. Which medication may be given first to
protect the myocardium?
A. Oral sodium chloride
B. IV calcium
C. Vitamin K
D. Naloxone
Correct Answer: B. IV calcium
Rationale: IV calcium stabilizes cardiac membranes in severe hyperkalemia with ECG changes while therapies to
shift/remove potassium are initiated.
18. A client receiving continuous IV insulin has glucose falling rapidly and potassium 3.2 mEq/L. Which
action should the nurse anticipate?
A. Adjust treatment and replace potassium according to protocol before severe hypokalemia develops
B. Give IV potassium push
C. Increase insulin without reviewing potassium
D. Stop all monitoring
Correct Answer: A. Adjust treatment and replace potassium according to protocol before severe hypokalemia
develops
Rationale: Insulin drives potassium intracellularly; low potassium during insulin infusion requires prompt
protocol-guided replacement and dose coordination.
WITH ANSWERS AND EXPLANATIONS
1. A nurse observes a provider entering a procedure room without performing required hand hygiene.
What should the nurse do?
A. Ignore it because the provider is senior
B. Document it only after the procedure without intervening
C. Ask the client to confront the provider
D. Speak up promptly to protect the client and reinforce the safety standard
Correct Answer: D. Speak up promptly to protect the client and reinforce the safety standard
Rationale: Safety culture supports respectful real-time intervention when a preventable infection-control breach
is observed.
2. A client receiving continuous enteral nutrition is prescribed phenytoin. What should the nurse
recognize?
A. Phenytoin must always be mixed into the formula bag
B. Drug levels are never needed
C. Enteral feeding can reduce phenytoin absorption, so administration and levels may need coordination
D. Enteral feeding doubles phenytoin absorption predictably
Correct Answer: C. Enteral feeding can reduce phenytoin absorption, so administration and levels may need
coordination
Rationale: Phenytoin absorption can be reduced by enteral feeds; timing and therapeutic monitoring should
follow pharmacy/provider guidance.
3. A client wants to designate a surrogate decision-maker. Which document is most directly used for this
purpose?
A. Medication administration record
B. Durable power of attorney for health care/health-care proxy according to local law
C. Incident report
D. Staff assignment sheet
Correct Answer: B. Durable power of attorney for health care/health-care proxy according to local law
Rationale: A health-care proxy or durable power of attorney for health care designates a surrogate to make health
decisions when the client cannot.
4. A client with suspected C. difficile diarrhea needs a portable commode. What is the best equipment
practice?
A. Share it between clients without cleaning
B. Dedicate the commode to the client and disinfect it with an effective sporicidal process
C. Clean it only with plain water once weekly
D. Store it in the hallway after use
Correct Answer: B. Dedicate the commode to the client and disinfect it with an effective sporicidal process
Rationale: C. difficile spores persist in the environment, so dedicated equipment and effective sporicidal cleaning
are important.
5. A client prescribed levodopa/carbidopa asks about stopping the drug suddenly. Which response is best?
A. Stop whenever symptoms improve
B. Do not stop abruptly without prescriber guidance because severe worsening can occur
C. Double the dose after missed doses
D. Take only on days with tremor
Correct Answer: B. Do not stop abruptly without prescriber guidance because severe worsening can occur
Rationale: Abrupt withdrawal can cause severe rigidity, immobility, or neuroleptic-malignant-like syndromes;
therapy should be adjusted with guidance.
6. The RN delegates ambulation of a stable client to UAP. Which statement reflects proper delegation?
A. The UAP assumes full nursing accountability
B. No follow-up is needed
C. The RN remains accountable for evaluating the outcome
D. The RN may delegate assessment and nursing diagnosis at the same time
,Correct Answer: C. The RN remains accountable for evaluating the outcome
Rationale: Delegation transfers performance of a task, not RN accountability for assessment, supervision, and
evaluation.
7. A client has a draining wound infected with multidrug-resistant organism. Which equipment practice is
best?
A. Dedicate noncritical equipment to the client or disinfect it before reuse
B. Share the same blood pressure cuff without cleaning
C. Store contaminated supplies in the hallway
D. Reuse disposable gloves
Correct Answer: A. Dedicate noncritical equipment to the client or disinfect it before reuse
Rationale: Dedicated or properly disinfected equipment reduces contact transmission.
8. A client with pulmonary embolism becomes suddenly hypotensive and syncopal. Which complication is
most likely?
A. Mild bronchitis
B. Stable chronic venous insufficiency
C. Simple anxiety
D. Massive PE with obstructive shock
Correct Answer: D. Massive PE with obstructive shock
Rationale: Sudden hypotension/syncope in PE suggests major obstruction of pulmonary circulation and
right-heart failure.
9. A client on long-term corticosteroids develops fever and cough. Why should the nurse take these
symptoms seriously?
A. Corticosteroids prevent all infections
B. Fever cannot occur while taking steroids
C. Corticosteroids can suppress immune responses and mask infection severity
D. Cough is always medication withdrawal
Correct Answer: C. Corticosteroids can suppress immune responses and mask infection severity
Rationale: Chronic corticosteroids increase infection risk and can blunt inflammatory signs, so new symptoms
warrant evaluation.
10. Which situation requires the nurse to use the chain of command?
A. A client requests a different breakfast item
B. A provider does not respond to repeated reports of a rapidly deteriorating client
C. A family asks visiting hours
D. A stable client wants a blanket
Correct Answer: B. A provider does not respond to repeated reports of a rapidly deteriorating client
Rationale: When a serious safety concern remains unresolved, escalation through the chain of command is
appropriate.
11. A client with chest trauma suddenly becomes hypotensive with distended neck veins and muffled heart
sounds. Which condition should the nurse suspect?
A. Left-sided heart failure
B. Simple rib fracture
C. Cardiac tamponade
D. Pulmonary fibrosis
Correct Answer: C. Cardiac tamponade
Rationale: Hypotension, JVD, and muffled heart sounds are classic findings of cardiac tamponade and
obstructive shock.
12. A client with seizure disorder is admitted. Which room setup is safest?
A. Padded tongue blade at bedside for insertion
B. Four side rails raised with restraints tied to them
C. Room farthest from staff without call bell
D. Bed low, suction and oxygen available, and seizure precautions in place
Correct Answer: D. Bed low, suction and oxygen available, and seizure precautions in place
Rationale: Seizure precautions emphasize injury prevention and airway support; objects should not be placed in
the mouth.
, 13. A client on clozapine reports fever and sore throat. Which action is most important?
A. Give the next dose early
B. Assume this is seasonal allergy
C. Obtain urgent evaluation of the absolute neutrophil count
D. Start a live vaccine
Correct Answer: C. Obtain urgent evaluation of the absolute neutrophil count
Rationale: Clozapine can cause severe neutropenia; infection symptoms require prompt blood count assessment
and
medication guidance.
14. A client with limited health literacy is learning a complex medication schedule. Which teaching method
is best?
A. Provide only a dense technical handout
B. Ask, "Do you understand?" and end teaching after yes
C. Use plain language and teach-back in small chunks
D. Use unexplained abbreviations
Correct Answer: C. Use plain language and teach-back in small chunks
Rationale: Plain language, chunking, and teach-back better assess and support comprehension than yes/no
questions.
15. A client with SIADH has sodium 116 mEq/L, headache, and confusion. Which nursing action is
priority?
A. Encourage unrestricted free water intake
B. Administer hypotonic IV fluid rapidly
C. Provide a high-potassium diet only
D. Institute seizure precautions and manage severe hyponatremia as prescribed
Correct Answer: D. Institute seizure precautions and manage severe hyponatremia as prescribed
Rationale: Severe symptomatic hyponatremia can cause seizures and cerebral edema; safety and controlled
correction are priorities.
16. A client with disseminated herpes zoster is admitted. Which precautions are appropriate?
A. Droplet precautions only
B. Standard precautions only
C. Protective isolation only
D. Airborne and contact precautions
Correct Answer: D. Airborne and contact precautions
Rationale: Disseminated zoster requires airborne and contact precautions until lesions are appropriately managed
and no longer infectious.
17. A client with severe hyperkalemia has widened QRS complexes. Which medication may be given first to
protect the myocardium?
A. Oral sodium chloride
B. IV calcium
C. Vitamin K
D. Naloxone
Correct Answer: B. IV calcium
Rationale: IV calcium stabilizes cardiac membranes in severe hyperkalemia with ECG changes while therapies to
shift/remove potassium are initiated.
18. A client receiving continuous IV insulin has glucose falling rapidly and potassium 3.2 mEq/L. Which
action should the nurse anticipate?
A. Adjust treatment and replace potassium according to protocol before severe hypokalemia develops
B. Give IV potassium push
C. Increase insulin without reviewing potassium
D. Stop all monitoring
Correct Answer: A. Adjust treatment and replace potassium according to protocol before severe hypokalemia
develops
Rationale: Insulin drives potassium intracellularly; low potassium during insulin infusion requires prompt
protocol-guided replacement and dose coordination.
