HESI EXIT PN ACTUAL EXAM
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES GRADED A+
LATEST
1. A client with chronic obstructive pulmonary disease (COPD) is admitted
with increased dyspnea and a productive cough. Which nursing action is the
priority?
A. Encourage coughing and deep breathing
B. Administer prescribed antibiotics
C. Obtain a sputum culture
D. Monitor oxygen saturation
Answer: D. Monitor oxygen saturation
Rationale: The priority is always to assess and maintain airway and oxygenation.
While the other interventions are important, monitoring oxygen saturation
addresses the immediate threat to life.
2. A nurse is caring for a client who is 1-day postoperative following
abdominal surgery. The client reports severe incisional pain, but the
prescription is for PRN analgesics. Which action should the nurse take?
A. Offer ice packs to the incision
B. Administer the prescribed PRN analgesic
C. Tell the client to wait until the next scheduled dose
D. Teach the client relaxation techniques
Answer: B. Administer the prescribed PRN analgesic
Rationale: Pain management is a priority. PRN medications should be
administered as needed to maintain comfort, which also promotes healing and
mobility.
,3. A client receiving IV potassium chloride develops redness and swelling at
the IV site. What is the nurse’s first action?
A. Slow the infusion rate
B. Apply a warm compress
C. Discontinue the IV
D. Notify the provider
Answer: C. Discontinue the IV
Rationale: IV potassium is a vesicant and can cause tissue damage. The nurse
should immediately stop the infusion to prevent infiltration or extravasation injury.
4. A nurse is assessing a client with heart failure who has gained 3 kg in 3
days. Which assessment finding is most concerning?
A. Mild dyspnea on exertion
B. Pitting edema in the ankles
C. Crackles in both lungs
D. Increased appetite
Answer: C. Crackles in both lungs
Rationale: Crackles indicate pulmonary congestion, which can be life-threatening
if not addressed. Rapid weight gain is also concerning, but lung assessment reflects
immediate risk.
5. A client with type 1 diabetes mellitus presents with nausea, vomiting,
abdominal pain, and fruity-smelling breath. Which lab value should the nurse
review first?
A. Blood glucose
B. Serum sodium
C. Hemoglobin A1c
D. Potassium
Answer: A. Blood glucose
Rationale: Symptoms suggest diabetic ketoacidosis (DKA). Hyperglycemia is the
immediate concern; blood glucose must be evaluated and managed promptly.
,6. The nurse is providing teaching to a client prescribed warfarin. Which
statement indicates understanding?
A. “I will avoid foods high in vitamin K.”
B. “I should take aspirin if I have a headache.”
C. “I can stop the medication once my INR is normal.”
D. “I do not need to have regular blood tests.”
Answer: A. “I will avoid foods high in vitamin K.”
Rationale: Vitamin K can reverse the effects of warfarin. Clients must also have
regular INR monitoring and avoid medications that increase bleeding risk.
7. A client is receiving oxygen via nasal cannula at 3 L/min. The nurse notes
oxygen saturation of 88% and increased respiratory effort. Which action is
appropriate?
A. Increase oxygen to 4 L/min
B. Apply a non-rebreather mask
C. Encourage the client to breathe slowly
D. Notify the provider
Answer: D. Notify the provider
Rationale: Saturation below 90% indicates hypoxemia. The nurse should notify
the provider before making changes to oxygen delivery if outside protocol.
8. A nurse is planning care for a client with stage 2 pressure injury on the
sacrum. Which intervention is most important?
A. Apply a moisture-retentive dressing
B. Massage around the wound edges
C. Encourage ambulation every 2 hours
D. Use a donut-shaped cushion
Answer: A. Apply a moisture-retentive dressing
Rationale: Moisture-retentive dressings promote healing by protecting the wound
, and maintaining a moist environment. Donut cushions can increase pressure on
surrounding tissue.
9. A client with a nasogastric (NG) tube reports nausea and abdominal
distention. The nurse notes that the NG tube is not draining. Which action
should the nurse take first?
A. Irrigate the tube with sterile water
B. Reposition the client to the left side
C. Notify the provider
D. Remove the NG tube
Answer: B. Reposition the client to the left side
Rationale: Repositioning can help relieve obstruction. Irrigation is second, but
only if there is no contraindication. Immediate removal is not the first action.
10. A nurse is caring for a client with hypothyroidism. Which assessment
finding requires immediate intervention?
A. Fatigue
B. Bradycardia
C. Dry skin
D. Constipation
Answer: B. Bradycardia
Rationale: Severe bradycardia can indicate myxedema and is potentially life-
threatening. Other symptoms are expected and chronic.
11. A nurse is teaching a client about insulin administration. Which statement
indicates correct understanding?
A. “I should rotate injection sites within the same region.”
B. “I can reuse my insulin syringes to save money.”
C. “I should massage the site after injection.”
D. “I should inject insulin into the muscle.”
QUESTIONS AND CORRECT ANSWERS
WITH RATIONALES GRADED A+
LATEST
1. A client with chronic obstructive pulmonary disease (COPD) is admitted
with increased dyspnea and a productive cough. Which nursing action is the
priority?
A. Encourage coughing and deep breathing
B. Administer prescribed antibiotics
C. Obtain a sputum culture
D. Monitor oxygen saturation
Answer: D. Monitor oxygen saturation
Rationale: The priority is always to assess and maintain airway and oxygenation.
While the other interventions are important, monitoring oxygen saturation
addresses the immediate threat to life.
2. A nurse is caring for a client who is 1-day postoperative following
abdominal surgery. The client reports severe incisional pain, but the
prescription is for PRN analgesics. Which action should the nurse take?
A. Offer ice packs to the incision
B. Administer the prescribed PRN analgesic
C. Tell the client to wait until the next scheduled dose
D. Teach the client relaxation techniques
Answer: B. Administer the prescribed PRN analgesic
Rationale: Pain management is a priority. PRN medications should be
administered as needed to maintain comfort, which also promotes healing and
mobility.
,3. A client receiving IV potassium chloride develops redness and swelling at
the IV site. What is the nurse’s first action?
A. Slow the infusion rate
B. Apply a warm compress
C. Discontinue the IV
D. Notify the provider
Answer: C. Discontinue the IV
Rationale: IV potassium is a vesicant and can cause tissue damage. The nurse
should immediately stop the infusion to prevent infiltration or extravasation injury.
4. A nurse is assessing a client with heart failure who has gained 3 kg in 3
days. Which assessment finding is most concerning?
A. Mild dyspnea on exertion
B. Pitting edema in the ankles
C. Crackles in both lungs
D. Increased appetite
Answer: C. Crackles in both lungs
Rationale: Crackles indicate pulmonary congestion, which can be life-threatening
if not addressed. Rapid weight gain is also concerning, but lung assessment reflects
immediate risk.
5. A client with type 1 diabetes mellitus presents with nausea, vomiting,
abdominal pain, and fruity-smelling breath. Which lab value should the nurse
review first?
A. Blood glucose
B. Serum sodium
C. Hemoglobin A1c
D. Potassium
Answer: A. Blood glucose
Rationale: Symptoms suggest diabetic ketoacidosis (DKA). Hyperglycemia is the
immediate concern; blood glucose must be evaluated and managed promptly.
,6. The nurse is providing teaching to a client prescribed warfarin. Which
statement indicates understanding?
A. “I will avoid foods high in vitamin K.”
B. “I should take aspirin if I have a headache.”
C. “I can stop the medication once my INR is normal.”
D. “I do not need to have regular blood tests.”
Answer: A. “I will avoid foods high in vitamin K.”
Rationale: Vitamin K can reverse the effects of warfarin. Clients must also have
regular INR monitoring and avoid medications that increase bleeding risk.
7. A client is receiving oxygen via nasal cannula at 3 L/min. The nurse notes
oxygen saturation of 88% and increased respiratory effort. Which action is
appropriate?
A. Increase oxygen to 4 L/min
B. Apply a non-rebreather mask
C. Encourage the client to breathe slowly
D. Notify the provider
Answer: D. Notify the provider
Rationale: Saturation below 90% indicates hypoxemia. The nurse should notify
the provider before making changes to oxygen delivery if outside protocol.
8. A nurse is planning care for a client with stage 2 pressure injury on the
sacrum. Which intervention is most important?
A. Apply a moisture-retentive dressing
B. Massage around the wound edges
C. Encourage ambulation every 2 hours
D. Use a donut-shaped cushion
Answer: A. Apply a moisture-retentive dressing
Rationale: Moisture-retentive dressings promote healing by protecting the wound
, and maintaining a moist environment. Donut cushions can increase pressure on
surrounding tissue.
9. A client with a nasogastric (NG) tube reports nausea and abdominal
distention. The nurse notes that the NG tube is not draining. Which action
should the nurse take first?
A. Irrigate the tube with sterile water
B. Reposition the client to the left side
C. Notify the provider
D. Remove the NG tube
Answer: B. Reposition the client to the left side
Rationale: Repositioning can help relieve obstruction. Irrigation is second, but
only if there is no contraindication. Immediate removal is not the first action.
10. A nurse is caring for a client with hypothyroidism. Which assessment
finding requires immediate intervention?
A. Fatigue
B. Bradycardia
C. Dry skin
D. Constipation
Answer: B. Bradycardia
Rationale: Severe bradycardia can indicate myxedema and is potentially life-
threatening. Other symptoms are expected and chronic.
11. A nurse is teaching a client about insulin administration. Which statement
indicates correct understanding?
A. “I should rotate injection sites within the same region.”
B. “I can reuse my insulin syringes to save money.”
C. “I should massage the site after injection.”
D. “I should inject insulin into the muscle.”
