ESTUDYR
HESI EXIT RN V4 COMPREHENSIVE NCLEX-STYLE Q &A: NURSING
CARE, PHARMACOLOGY, PEDIATRICS & MED-SURG
1. The nurse is caring for a pre-adolescent child in skeletal Dunlop traction. Which nursing intervention is
most appropriate?
A) Be sure the traction weights touch the end of the bed
B) Adjust the head and foot of the bed for the child's comfort
✅C) Make certain the child is maintained in correct body alignment
D) Release the traction for 15–20 minutes every 6 hours PRN
Rationale: Correct body alignment is critical in maintaining effective traction and preventing
complications such as nerve or muscle damage. The weights should hang freely and never touch the bed
or floor.
2. During a routine 2-year check-up, which finding should the nurse report immediately to the
healthcare provider?
✅A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short-term weight changes are uneven
Rationale: Wide variation between height and weight percentiles may indicate a potential underlying
health or nutritional issue that warrants immediate evaluation.
3. Parents report their 2-year-old holds his breath during temper tantrums. What is the best nursing
action?
A) Teach CPR to the parents
B) Recommend giving in to avoid anoxia
✅C) Advise the parents to ignore breath-holding as breathing will resume reflexively
D) Teach reasoning strategies to avoid future episodes
Rationale: Breath-holding is common in toddlers and typically self-limited. It is not dangerous, as
breathing resumes involuntarily. Reinforcing it may worsen the behavior.
4. Which client statement best suggests acute angina?
,ESTUDYR
✅A) “My pain is deep in my chest behind my sternum.”
B) “When I sit up the pain gets worse.”
C) “As I take a deep breath the pain gets worse.”
D) “The pain is right here in my stomach area.”
Rationale: Substernal chest pain is a classic symptom of angina pectoris, especially if associated with
exertion and relieved by rest or nitroglycerin.
5. When assessing a client with suspected organic brain disorder, which question best evaluates recent
memory?
A) “Name the year. What season is this?”
B) “Subtract 7 from 100 and keep going.”
✅C) “Repeat these three words after me: blue, ball, pen.”
D) “What is this on my wrist?” (points to watch)
Rationale: Repetition and recall of a word list is a standard way to assess recent memory function. This
evaluates short-term recall ability effectively.
6. What should the nurse provide to assist in the development of trust in a 6-month-old?
A) Food
B) Warmth
✅C) Security
D) Comfort
Rationale: According to Erikson’s psychosocial stages, infants develop trust when caregivers consistently
provide secure and reliable care.
7. A nurse receives an illegible medication order. What is the most appropriate and assertive response?
A) “I cannot give this as it is written.”
✅B) “Would you please clarify what you have written so I can ensure it's correct?”
C) “It would save me time if you wrote more clearly.”
D) “Please print your orders from now on.”
Rationale: Assertive communication focuses on clarity, respect, and patient safety without blame.
Requesting clarification is professional and necessary.
,ESTUDYR
8. What is the most important consideration when teaching parents about reducing risks in the home?
A) Age and knowledge level of parents
B) Proximity to emergency services
C) Number of children in the home
✅D) Age of children in the home
Rationale: Safety education should be developmentally appropriate. The child's age determines physical
abilities and types of risks (e.g., choking, burns, falls).
9. A 35-year-old client with sickle cell crisis requests pain relief while on the phone. What should the
nurse do?
A) Administer a placebo
B) Encourage increased fluids
✅C) Administer the prescribed analgesic
D) Recommend relaxation techniques
Rationale: Pain is a hallmark of sickle cell crisis and should be treated promptly. Requesting pain relief—
even while engaged in another activity—is valid.
10. A toddler with croup is being monitored. Which sign requires immediate attention?
✅A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
Rationale: A high respiratory rate suggests respiratory distress and potential airway obstruction,
especially in a child with croup, requiring urgent action.
11. A child is admitted with suspected epiglottitis. What is the nurse’s priority action?
A) Encourage the child to cough
✅B) Notify the healthcare provider immediately
C) Attempt to visualize the throat
D) Start a throat culture
Rationale: Epiglottitis is a medical emergency due to the risk of sudden airway obstruction. The throat
should not be visualized, as this can trigger complete closure.
, ESTUDYR
12. Which of the following would most help a hospitalized preschooler cope with separation anxiety?
✅A) Encouraging rooming-in with the parent
B) Explaining the reason for hospitalization
C) Offering the child a hospital tour
D) Allowing unlimited TV time
Rationale: Rooming-in allows consistency and attachment, which is critical at the preschool stage to
reduce fear and anxiety due to separation.
13. A client asks, “Why am I taking both isoniazid and rifampin for TB?” Which response is best?
A) “They both work the same way to kill the bacteria faster.”
✅B) “Using multiple drugs reduces the chance of the bacteria becoming drug-resistant.”
C) “Taking two drugs decreases side effects.”
D) “This is standard treatment to shorten your therapy time.”
Rationale: Combination therapy is used in TB to prevent resistance, especially since Mycobacterium
tuberculosis mutates quickly.
14. A client with schizophrenia is experiencing auditory hallucinations. What is the best initial nursing
action?
A) Ask detailed questions about the voices
✅B) Acknowledge that the client is hearing voices and offer distraction
C) Challenge the client’s beliefs
D) Tell the client the voices are not real
Rationale: Validation and redirection are therapeutic. Denying the hallucination may escalate distress,
while acknowledgment builds trust.
15. A nurse is preparing to administer digoxin to an infant. The apical pulse is 78. What should the nurse
do?
A) Administer the medication
B) Recheck in 15 minutes
✅C) Hold the medication and notify the provider
D) Give half the dose
Rationale: For infants, if the apical pulse is below 90–110 bpm, digoxin should be held. Bradycardia may
indicate toxicity.
HESI EXIT RN V4 COMPREHENSIVE NCLEX-STYLE Q &A: NURSING
CARE, PHARMACOLOGY, PEDIATRICS & MED-SURG
1. The nurse is caring for a pre-adolescent child in skeletal Dunlop traction. Which nursing intervention is
most appropriate?
A) Be sure the traction weights touch the end of the bed
B) Adjust the head and foot of the bed for the child's comfort
✅C) Make certain the child is maintained in correct body alignment
D) Release the traction for 15–20 minutes every 6 hours PRN
Rationale: Correct body alignment is critical in maintaining effective traction and preventing
complications such as nerve or muscle damage. The weights should hang freely and never touch the bed
or floor.
2. During a routine 2-year check-up, which finding should the nurse report immediately to the
healthcare provider?
✅A) Height and weight percentiles vary widely
B) Growth pattern appears to have slowed
C) Recumbent and standing height are different
D) Short-term weight changes are uneven
Rationale: Wide variation between height and weight percentiles may indicate a potential underlying
health or nutritional issue that warrants immediate evaluation.
3. Parents report their 2-year-old holds his breath during temper tantrums. What is the best nursing
action?
A) Teach CPR to the parents
B) Recommend giving in to avoid anoxia
✅C) Advise the parents to ignore breath-holding as breathing will resume reflexively
D) Teach reasoning strategies to avoid future episodes
Rationale: Breath-holding is common in toddlers and typically self-limited. It is not dangerous, as
breathing resumes involuntarily. Reinforcing it may worsen the behavior.
4. Which client statement best suggests acute angina?
,ESTUDYR
✅A) “My pain is deep in my chest behind my sternum.”
B) “When I sit up the pain gets worse.”
C) “As I take a deep breath the pain gets worse.”
D) “The pain is right here in my stomach area.”
Rationale: Substernal chest pain is a classic symptom of angina pectoris, especially if associated with
exertion and relieved by rest or nitroglycerin.
5. When assessing a client with suspected organic brain disorder, which question best evaluates recent
memory?
A) “Name the year. What season is this?”
B) “Subtract 7 from 100 and keep going.”
✅C) “Repeat these three words after me: blue, ball, pen.”
D) “What is this on my wrist?” (points to watch)
Rationale: Repetition and recall of a word list is a standard way to assess recent memory function. This
evaluates short-term recall ability effectively.
6. What should the nurse provide to assist in the development of trust in a 6-month-old?
A) Food
B) Warmth
✅C) Security
D) Comfort
Rationale: According to Erikson’s psychosocial stages, infants develop trust when caregivers consistently
provide secure and reliable care.
7. A nurse receives an illegible medication order. What is the most appropriate and assertive response?
A) “I cannot give this as it is written.”
✅B) “Would you please clarify what you have written so I can ensure it's correct?”
C) “It would save me time if you wrote more clearly.”
D) “Please print your orders from now on.”
Rationale: Assertive communication focuses on clarity, respect, and patient safety without blame.
Requesting clarification is professional and necessary.
,ESTUDYR
8. What is the most important consideration when teaching parents about reducing risks in the home?
A) Age and knowledge level of parents
B) Proximity to emergency services
C) Number of children in the home
✅D) Age of children in the home
Rationale: Safety education should be developmentally appropriate. The child's age determines physical
abilities and types of risks (e.g., choking, burns, falls).
9. A 35-year-old client with sickle cell crisis requests pain relief while on the phone. What should the
nurse do?
A) Administer a placebo
B) Encourage increased fluids
✅C) Administer the prescribed analgesic
D) Recommend relaxation techniques
Rationale: Pain is a hallmark of sickle cell crisis and should be treated promptly. Requesting pain relief—
even while engaged in another activity—is valid.
10. A toddler with croup is being monitored. Which sign requires immediate attention?
✅A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions
Rationale: A high respiratory rate suggests respiratory distress and potential airway obstruction,
especially in a child with croup, requiring urgent action.
11. A child is admitted with suspected epiglottitis. What is the nurse’s priority action?
A) Encourage the child to cough
✅B) Notify the healthcare provider immediately
C) Attempt to visualize the throat
D) Start a throat culture
Rationale: Epiglottitis is a medical emergency due to the risk of sudden airway obstruction. The throat
should not be visualized, as this can trigger complete closure.
, ESTUDYR
12. Which of the following would most help a hospitalized preschooler cope with separation anxiety?
✅A) Encouraging rooming-in with the parent
B) Explaining the reason for hospitalization
C) Offering the child a hospital tour
D) Allowing unlimited TV time
Rationale: Rooming-in allows consistency and attachment, which is critical at the preschool stage to
reduce fear and anxiety due to separation.
13. A client asks, “Why am I taking both isoniazid and rifampin for TB?” Which response is best?
A) “They both work the same way to kill the bacteria faster.”
✅B) “Using multiple drugs reduces the chance of the bacteria becoming drug-resistant.”
C) “Taking two drugs decreases side effects.”
D) “This is standard treatment to shorten your therapy time.”
Rationale: Combination therapy is used in TB to prevent resistance, especially since Mycobacterium
tuberculosis mutates quickly.
14. A client with schizophrenia is experiencing auditory hallucinations. What is the best initial nursing
action?
A) Ask detailed questions about the voices
✅B) Acknowledge that the client is hearing voices and offer distraction
C) Challenge the client’s beliefs
D) Tell the client the voices are not real
Rationale: Validation and redirection are therapeutic. Denying the hallucination may escalate distress,
while acknowledgment builds trust.
15. A nurse is preparing to administer digoxin to an infant. The apical pulse is 78. What should the nurse
do?
A) Administer the medication
B) Recheck in 15 minutes
✅C) Hold the medication and notify the provider
D) Give half the dose
Rationale: For infants, if the apical pulse is below 90–110 bpm, digoxin should be held. Bradycardia may
indicate toxicity.
