2025 HESI EXIT RN V1 EXAM WITH
NGN
Patient: Jane Doe, a 62-year-old female with a history of type 2 diabetes and
hypertension, is admitted with shortness of breath and chest pain. Her vitals are: BP
150/90 mmHg, HR 98 bpm, RR 22/min, SpO2 91% on room air, and blood glucose
240 mg/dL. She reports feeling lightheaded and nauseous.
Which nursing action should the nurse prioritize?
A. Administer nitroglycerin tablet sublingually
B. Obtain a 12-lead ECG immediately
C. Encourage the patient to take deep breaths
D. Monitor the patient’s glucose every hour
Answer: B
Rationale: A 12-lead ECG should be performed immediately to rule out myocardial
infarction, given her chest pain and history of hypertension.
The ECG reveals ST-segment elevation. What is the most appropriate action?
A. Administer aspirin 325 mg orally
B. Initiate IV insulin therapy
C. Position the patient in high Fowler’s
D. Restrict fluids and begin strict I&O monitoring
Answer: A
Rationale: Administration of aspirin is critical in managing ST-elevation myocardial
infarction (STEMI) to prevent clot progression.
Using a matrix, identify which assessments are relevant to this patient:
Assessments Relevant (Yes/No)
Lung auscultation Yes
,Blood culture No
Continuous ECG monitoring Yes
Peak expiratory flow rate No
What lab result would the nurse monitor closely given the patient’s history and
symptoms?
A. Troponin
B. Hemoglobin A1c
C. White blood cell (WBC) count
D. Serum sodium
Answer: A
Rationale: Troponin is a key biomarker for myocardial damage and is critical to
evaluate in cases of suspected acute coronary syndrome.
Traditional Multiple-Choice Questions
A nurse is caring for a patient who is receiving IV furosemide for heart failure. Which
electrolyte imbalance is most likely to occur?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypoglycemia
Answer: C
Rationale: Furosemide is a loop diuretic that can lead to significant potassium loss,
resulting in hypokalemia.
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy at 4 L/min. Which assessment finding requires immediate intervention?
A. SpO2 92%
B. Respiratory rate of 24 breaths/min
C. Patient complains of a mild headache
, D. Patient becomes drowsy and difficult to arouse
Answer: D
Rationale: Drowsiness and decreased level of consciousness could indicate carbon
dioxide retention, a concern in COPD patients on high-flow oxygen.
Which nursing diagnosis is most appropriate for a patient experiencing acute pain
postoperatively?
A. Risk for infection
B. Impaired physical mobility
C. Activity intolerance
D. Ineffective airway clearance
Answer: B
Rationale: Acute pain can limit a patient’s ability to move effectively, which makes
"Impaired physical mobility" the most relevant diagnosis.
A nurse is administering warfarin to a patient with atrial fibrillation. Which lab value
should the nurse monitor to evaluate the therapeutic effect of the medication?
A. Hemoglobin
B. International Normalized Ratio (INR)
C. Platelet count
D. Activated partial thromboplastin time (aPTT)
Answer: B
Rationale: The INR is used to monitor the therapeutic effect of warfarin and ensure it
is within the target range.
A patient receiving blood transfusion suddenly reports chills, back pain, and
shortness of breath. What is the nurse's priority action?
A. Slow the infusion rate
B. Stop the transfusion immediately
NGN
Patient: Jane Doe, a 62-year-old female with a history of type 2 diabetes and
hypertension, is admitted with shortness of breath and chest pain. Her vitals are: BP
150/90 mmHg, HR 98 bpm, RR 22/min, SpO2 91% on room air, and blood glucose
240 mg/dL. She reports feeling lightheaded and nauseous.
Which nursing action should the nurse prioritize?
A. Administer nitroglycerin tablet sublingually
B. Obtain a 12-lead ECG immediately
C. Encourage the patient to take deep breaths
D. Monitor the patient’s glucose every hour
Answer: B
Rationale: A 12-lead ECG should be performed immediately to rule out myocardial
infarction, given her chest pain and history of hypertension.
The ECG reveals ST-segment elevation. What is the most appropriate action?
A. Administer aspirin 325 mg orally
B. Initiate IV insulin therapy
C. Position the patient in high Fowler’s
D. Restrict fluids and begin strict I&O monitoring
Answer: A
Rationale: Administration of aspirin is critical in managing ST-elevation myocardial
infarction (STEMI) to prevent clot progression.
Using a matrix, identify which assessments are relevant to this patient:
Assessments Relevant (Yes/No)
Lung auscultation Yes
,Blood culture No
Continuous ECG monitoring Yes
Peak expiratory flow rate No
What lab result would the nurse monitor closely given the patient’s history and
symptoms?
A. Troponin
B. Hemoglobin A1c
C. White blood cell (WBC) count
D. Serum sodium
Answer: A
Rationale: Troponin is a key biomarker for myocardial damage and is critical to
evaluate in cases of suspected acute coronary syndrome.
Traditional Multiple-Choice Questions
A nurse is caring for a patient who is receiving IV furosemide for heart failure. Which
electrolyte imbalance is most likely to occur?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypoglycemia
Answer: C
Rationale: Furosemide is a loop diuretic that can lead to significant potassium loss,
resulting in hypokalemia.
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen
therapy at 4 L/min. Which assessment finding requires immediate intervention?
A. SpO2 92%
B. Respiratory rate of 24 breaths/min
C. Patient complains of a mild headache
, D. Patient becomes drowsy and difficult to arouse
Answer: D
Rationale: Drowsiness and decreased level of consciousness could indicate carbon
dioxide retention, a concern in COPD patients on high-flow oxygen.
Which nursing diagnosis is most appropriate for a patient experiencing acute pain
postoperatively?
A. Risk for infection
B. Impaired physical mobility
C. Activity intolerance
D. Ineffective airway clearance
Answer: B
Rationale: Acute pain can limit a patient’s ability to move effectively, which makes
"Impaired physical mobility" the most relevant diagnosis.
A nurse is administering warfarin to a patient with atrial fibrillation. Which lab value
should the nurse monitor to evaluate the therapeutic effect of the medication?
A. Hemoglobin
B. International Normalized Ratio (INR)
C. Platelet count
D. Activated partial thromboplastin time (aPTT)
Answer: B
Rationale: The INR is used to monitor the therapeutic effect of warfarin and ensure it
is within the target range.
A patient receiving blood transfusion suddenly reports chills, back pain, and
shortness of breath. What is the nurse's priority action?
A. Slow the infusion rate
B. Stop the transfusion immediately
