HESI RN Exit Exam V1 –
2025 Updated Full Questions
& Verified 100% Correct
Answers
Section 1: Safe and Effective Care Environment
(Questions 1–40)
1. A nurse is planning care for a client admitted with a suspected stroke. The
priority nursing action is to: A. Administer tissue plasminogen activator if
indicated B. Obtain a stat CT scan of the head C. Prepare for thrombolytic therapy
D. Assess neurological status using the NIH Stroke Scale
Rationale: Per NCSBN 2025 Physiological Integrity (Reduction of Risk
Potential), obtaining a CT scan is the priority to rule out hemorrhage before
thrombolytics, ensuring patient safety by preventing exacerbation of bleeding; this
supports timely intervention within the 4.5-hour window.
2. An RN is delegating tasks to an LPN and UAP. Which task should the RN
perform personally? A. Monitoring a client's blood glucose B. Assessing a client
for signs of respiratory distress C. Assisting with ambulation D. Recording intake
and output
Rationale: NCSBN 2025 Safe and Effective Care (Management of Care) requires
RN assessment for unstable conditions like respiratory distress, involving clinical
judgment; delegation to LPN/UAP is appropriate for stable monitoring to optimize
team efficiency.
3. A nurse enters a client's room and finds the client unresponsive with no
pulse. The priority action is: A. Call for help and start CPR B. Call for help and
start CPR C. Check for a DNR order D. Administer epinephrine
,Rationale: NCSBN 2025 Safe and Effective Care (Safety) follows BLS protocols:
activate emergency response and initiate CPR immediately for pulselessness,
prioritizing circulation; DNR verification follows if time allows.
4. A nurse is preparing to administer a blood transfusion. The priority
verification step is: A. Checking the client's ID bracelet B. Two-nurse check of
client ID, blood type, and unit number C. Confirming the client's diagnosis D.
Assessing vital signs
Rationale: NCSBN 2025 Reduction of Risk Potential mandates two-person
verification to prevent ABO incompatibility reactions, a sentinel event; this ensures
patient safety through error prevention.
5. A client with a new tracheostomy is at risk for aspiration. The nurse's
priority intervention is: A. Perform suctioning q4h B. Elevate the head of the bed
30–45 degrees C. Provide oral care with chlorhexidine D. Humidify inspired air
Rationale: NCSBN 2025 Basic Care and Comfort positions the HOB to reduce
reflux and aspiration risk in ventilated clients, per INS 2025 guidelines; this
promotes safety during feeding.
6. A nurse is delegating care to a UAP. Which client activity can the UAP
safely perform? A. Assessing a wound for infection B. Taking vital signs on a
stable postoperative client C. Administering oral medications D. Planning
discharge teaching
Rationale: NCSBN 2025 Management of Care allows UAP to perform routine VS
under RN supervision for stable clients, following the five rights of delegation; RN
retains assessment and teaching.
7. A nurse is responding to a client's call light for pain. The priority action is:
A. Administer PRN medication B. Assess the pain using a standardized scale C.
Document the request D. Notify the physician
Rationale: NCSBN 2025 Physiological Integrity (Pharmacological Therapies)
requires pain assessment (e.g., 0–10 scale) before intervention to guide therapy and
evaluate effectiveness, ensuring client-centered care.
8. A client with a history of falls is prescribed a new medication. The nurse's
priority teaching is: A. Take with food B. Report dizziness immediately C.
Increase activity D. Drive to appointments
, Rationale: NCSBN 2025 Health Promotion (Lifestyle Changes) focuses on
orthostasis risk from antihypertensives, promoting safety by avoiding driving until
stable.
9. A nurse is caring for four clients. Which requires immediate intervention?
A. Client with BP 130/80 mmHg B. Client with HR 88 bpm C. Client with O2 sat
88% on room air D. Client with temp 99.2°F
Rationale: NCSBN 2025 Physiological Adaptation uses ABCs; hypoxemia (O2
sat <92%) threatens oxygenation, requiring supplemental O2 and provider
notification.
10. A nurse is preparing a client for discharge after a MI. The priority
education is: A. Dietary restrictions B. Signs of recurrent angina C. Exercise
program D. Medication schedule
Rationale: NCSBN 2025 Reduction of Risk Potential prioritizes symptom
recognition (chest pain, dyspnea) for early re-admission prevention, per AHA 2025
guidelines.
11. A UAP reports a client is short of breath. The RN's first action is: A.
Delegate oxygen application B. Assess the client C. Document the report D. Call
the physician
Rationale: NCSBN 2025 Management of Care: RN assessment is required for
acute changes; UAP reports but cannot diagnose.
12. A nurse is administering IV antibiotics. The priority site for infusion is: A.
Dorsal hand vein B. Large antecubital vein C. Foot vein D. Wrist vein
Rationale: NCSBN 2025 Pharmacological (Parenteral): Larger veins reduce
phlebitis risk for vesicants; flush with saline post-dose.
13. A client with a central line develops redness at the site. The nurse: A.
Apply warm compress B. Remove the line and culture the tip C. Increase flow D.
Ignore if afebrile
Rationale: NCSBN 2025 Infection Control: CRBSI signs require line removal per
CDC 2025; notify provider.
2025 Updated Full Questions
& Verified 100% Correct
Answers
Section 1: Safe and Effective Care Environment
(Questions 1–40)
1. A nurse is planning care for a client admitted with a suspected stroke. The
priority nursing action is to: A. Administer tissue plasminogen activator if
indicated B. Obtain a stat CT scan of the head C. Prepare for thrombolytic therapy
D. Assess neurological status using the NIH Stroke Scale
Rationale: Per NCSBN 2025 Physiological Integrity (Reduction of Risk
Potential), obtaining a CT scan is the priority to rule out hemorrhage before
thrombolytics, ensuring patient safety by preventing exacerbation of bleeding; this
supports timely intervention within the 4.5-hour window.
2. An RN is delegating tasks to an LPN and UAP. Which task should the RN
perform personally? A. Monitoring a client's blood glucose B. Assessing a client
for signs of respiratory distress C. Assisting with ambulation D. Recording intake
and output
Rationale: NCSBN 2025 Safe and Effective Care (Management of Care) requires
RN assessment for unstable conditions like respiratory distress, involving clinical
judgment; delegation to LPN/UAP is appropriate for stable monitoring to optimize
team efficiency.
3. A nurse enters a client's room and finds the client unresponsive with no
pulse. The priority action is: A. Call for help and start CPR B. Call for help and
start CPR C. Check for a DNR order D. Administer epinephrine
,Rationale: NCSBN 2025 Safe and Effective Care (Safety) follows BLS protocols:
activate emergency response and initiate CPR immediately for pulselessness,
prioritizing circulation; DNR verification follows if time allows.
4. A nurse is preparing to administer a blood transfusion. The priority
verification step is: A. Checking the client's ID bracelet B. Two-nurse check of
client ID, blood type, and unit number C. Confirming the client's diagnosis D.
Assessing vital signs
Rationale: NCSBN 2025 Reduction of Risk Potential mandates two-person
verification to prevent ABO incompatibility reactions, a sentinel event; this ensures
patient safety through error prevention.
5. A client with a new tracheostomy is at risk for aspiration. The nurse's
priority intervention is: A. Perform suctioning q4h B. Elevate the head of the bed
30–45 degrees C. Provide oral care with chlorhexidine D. Humidify inspired air
Rationale: NCSBN 2025 Basic Care and Comfort positions the HOB to reduce
reflux and aspiration risk in ventilated clients, per INS 2025 guidelines; this
promotes safety during feeding.
6. A nurse is delegating care to a UAP. Which client activity can the UAP
safely perform? A. Assessing a wound for infection B. Taking vital signs on a
stable postoperative client C. Administering oral medications D. Planning
discharge teaching
Rationale: NCSBN 2025 Management of Care allows UAP to perform routine VS
under RN supervision for stable clients, following the five rights of delegation; RN
retains assessment and teaching.
7. A nurse is responding to a client's call light for pain. The priority action is:
A. Administer PRN medication B. Assess the pain using a standardized scale C.
Document the request D. Notify the physician
Rationale: NCSBN 2025 Physiological Integrity (Pharmacological Therapies)
requires pain assessment (e.g., 0–10 scale) before intervention to guide therapy and
evaluate effectiveness, ensuring client-centered care.
8. A client with a history of falls is prescribed a new medication. The nurse's
priority teaching is: A. Take with food B. Report dizziness immediately C.
Increase activity D. Drive to appointments
, Rationale: NCSBN 2025 Health Promotion (Lifestyle Changes) focuses on
orthostasis risk from antihypertensives, promoting safety by avoiding driving until
stable.
9. A nurse is caring for four clients. Which requires immediate intervention?
A. Client with BP 130/80 mmHg B. Client with HR 88 bpm C. Client with O2 sat
88% on room air D. Client with temp 99.2°F
Rationale: NCSBN 2025 Physiological Adaptation uses ABCs; hypoxemia (O2
sat <92%) threatens oxygenation, requiring supplemental O2 and provider
notification.
10. A nurse is preparing a client for discharge after a MI. The priority
education is: A. Dietary restrictions B. Signs of recurrent angina C. Exercise
program D. Medication schedule
Rationale: NCSBN 2025 Reduction of Risk Potential prioritizes symptom
recognition (chest pain, dyspnea) for early re-admission prevention, per AHA 2025
guidelines.
11. A UAP reports a client is short of breath. The RN's first action is: A.
Delegate oxygen application B. Assess the client C. Document the report D. Call
the physician
Rationale: NCSBN 2025 Management of Care: RN assessment is required for
acute changes; UAP reports but cannot diagnose.
12. A nurse is administering IV antibiotics. The priority site for infusion is: A.
Dorsal hand vein B. Large antecubital vein C. Foot vein D. Wrist vein
Rationale: NCSBN 2025 Pharmacological (Parenteral): Larger veins reduce
phlebitis risk for vesicants; flush with saline post-dose.
13. A client with a central line develops redness at the site. The nurse: A.
Apply warm compress B. Remove the line and culture the tip C. Increase flow D.
Ignore if afebrile
Rationale: NCSBN 2025 Infection Control: CRBSI signs require line removal per
CDC 2025; notify provider.
