HESI RN EXIT V1 SET 2 NGN QUESTIONS
WITH ANSWERS AND EXPLANATIONS
Question 1.
A planned nursing response is to two qualified staff verify the client product unit number
blood type compatibility and expiration as required. Which finding should the nurse
connect most directly with the reason for this intervention?
A. Hand hygiene is the single most important routine action for reducing health-care
associated transmission.
B. Contaminated PPE should be removed to reduce self-contamination.
C. Blood products require strict identification and compatibility checks immediately before
administration.
D. Needles should be disposed of promptly in puncture-resistant sharps containers.
Correct Answer: C. Blood products require strict identification and compatibility
checks immediately before administration.
Explanation: The keyed option is the most direct response to the clinical problem in the
stem. The most characteristic cue or principle for Blood-product bedside verification is
blood products require strict identification and compatibility checks immediately before
administration. Safety decisions should interrupt exposure or injury risk while preserving
appropriate infection-control and surveillance measures. The distractors describe findings
associated with other nursing problems and therefore do not best identify the concept
being tested; the nurse should cluster this cue with the remaining history, assessment
data, and trends before choosing the next intervention.
Question 2.
The nurse anticipates the need to encourage talking reading and safe exploration rather
than screen-based stimulation. Which assessment pattern or principle should receive the
greatest weight?
A. Effective latch includes a wide-open mouth deep attachment and audible swallowing
without persistent nipple trauma.
B. Young infants show increasing social engagement and head control but still require full
support.
C. Many infants around six months begin sitting with support transferring objects and
responding socially.
D. Around one year many children pull to stand use simple gestures and may say a few
meaningful words.
Correct Answer: D. Around one year many children pull to stand use simple
gestures and may say a few meaningful words.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. The most characteristic cue or principle for
Twelve-month developmental expectations is around one year many children pull to stand
use simple gestures and may say a few meaningful words. Health-promotion care
emphasizes prevention, development, screening, immunization, anticipatory guidance,
,and early recognition of warning signs. The distractors describe findings associated with
other nursing problems and therefore do not best identify the concept being tested; the
nurse should cluster this cue with the remaining history, assessment data, and trends
before choosing the next intervention.
Question 3.
On a maternal-newborn unit, the nurse is preparing to correct volume chloride and
potassium deficits as ordered while treating the cause. Which assessment cue is most
consistent with the underlying problem?
A. MRI's strong magnetic field makes ferromagnetic implants and loose metal objects
hazardous.
B. Metabolic alkalosis features elevated bicarbonate and pH often from vomiting gastric
suction or diuretics.
C. Increasing pain numbness coolness delayed capillary refill or inability to move digits
may indicate impaired circulation or nerve compression.
D. Continuous bubbling in the water-seal chamber suggests an air leak somewhere in the
system or from the client.
Correct Answer: B. Metabolic alkalosis features elevated bicarbonate and pH
often from vomiting gastric suction or diuretics.
Explanation: This answer is the best match for the client data and the expected nursing
standard. The most characteristic cue or principle for Metabolic alkalosis is metabolic
alkalosis features elevated bicarbonate and pH often from vomiting gastric suction or
diuretics. Risk-reduction items depend on recognizing early complications, abnormal
trends, procedure-related hazards, and the need for timely escalation. The distractors
describe findings associated with other nursing problems and therefore do not best
identify the concept being tested; the nurse should cluster this cue with the remaining
history, assessment data, and trends before choosing the next intervention.
Question 4.
A 44-year-old client requires the nurse to the RN performs the admission assessment
before delegating routine care. Which cue most likely prompted this decision?
A. Initial comprehensive assessment requires RN clinical judgment.
B. Stable clients with predictable outcomes may receive routine medications from an LPN
according to scope.
C. Screening is most effective in private with direct nonjudgmental questions.
D. Verbal orders require accurate read-back and authentication according to policy.
Correct Answer: A. Initial comprehensive assessment requires RN clinical
judgment.
Explanation: The selected response is the most appropriate next step for the situation
presented. The most characteristic cue or principle for Initial nursing assessment is initial
comprehensive assessment requires RN clinical judgment. Management decisions must
account for acuity, scope of practice, client rights, communication, continuity, and RN
accountability. The distractors describe findings associated with other nursing problems
,and therefore do not best identify the concept being tested; the nurse should cluster this
cue with the remaining history, assessment data, and trends before choosing the next
intervention.
Question 5.
A 31-year-old client requires the nurse to check pulse and blood pressure before
administration and follow hold parameters. Which cue most likely prompted this decision?
A. ARBs lower blood pressure and can increase potassium and affect renal function.
B. NSAIDs can cause gastrointestinal bleeding kidney injury fluid retention and
cardiovascular risk.
C. Beta blockers reduce heart rate and blood pressure and can mask adrenergic symptoms
of hypoglycemia.
D. Rapid-acting insulin can cause hypoglycemia and is timed closely with carbohydrate
intake.
Correct Answer: C. Beta blockers reduce heart rate and blood pressure and can
mask adrenergic symptoms of hypoglycemia.
Explanation: The correct option most specifically addresses the safety or physiologic
issue described. The most characteristic cue or principle for Beta blockers is beta blockers
reduce heart rate and blood pressure and can mask adrenergic symptoms of
hypoglycemia. Medication decisions require attention to indication, dose, administration
safety, adverse effects, interactions, and response to therapy. The distractors describe
findings associated with other nursing problems and therefore do not best identify the
concept being tested; the nurse should cluster this cue with the remaining history,
assessment data, and trends before choosing the next intervention.
Question 6.
The nurse anticipates the need to do not administer feedings or medications until
placement has been verified according to policy. Which assessment pattern or principle
should receive the greatest weight?
A. Stage 3 pressure injury involves full-thickness skin loss with visible adipose tissue but
no exposed fascia muscle tendon or bone.
B. Enteral feeding safety includes tube-position verification per policy aspiration
precautions and appropriate head elevation.
C. Range-of-motion exercises preserve joint mobility and should be slow controlled and
within tolerance.
D. Initial feeding-tube placement is verified by an approved method before use and
external length is monitored thereafter.
Correct Answer: D. Initial feeding-tube placement is verified by an approved
method before use and external length is monitored thereafter.
Explanation: The selected response is the most appropriate next step for the situation
presented. The most characteristic cue or principle for Nasogastric tube placement is
initial feeding-tube placement is verified by an approved method before use and external
length is monitored thereafter. Basic-care decisions should preserve function, nutrition,
, elimination, mobility, skin integrity, comfort, and dignity without creating avoidable risk.
The distractors describe findings associated with other nursing problems and therefore do
not best identify the concept being tested; the nurse should cluster this cue with the
remaining history, assessment data, and trends before choosing the next intervention.
Question 7.
The care plan includes the response: monitor potassium creatinine and blood pressure
after initiation or dose changes. Which finding or principle would most strongly justify this
plan?
A. ARBs lower blood pressure and can increase potassium and affect renal function.
B. Isoniazid can cause hepatotoxicity and peripheral neuropathy and is often given with
pyridoxine.
C. Beta blockers reduce heart rate and blood pressure and can mask adrenergic symptoms
of hypoglycemia.
D. Benzodiazepines can cause sedation respiratory depression falls and dependence
especially with opioids or alcohol.
Correct Answer: A. ARBs lower blood pressure and can increase potassium and
affect renal function.
Explanation: The selected response is the most appropriate next step for the situation
presented. The most characteristic cue or principle for Angiotensin receptor blockers is
aRBs lower blood pressure and can increase potassium and affect renal function.
Medication decisions require attention to indication, dose, administration safety, adverse
effects, interactions, and response to therapy. The distractors describe findings associated
with other nursing problems and therefore do not best identify the concept being tested;
the nurse should cluster this cue with the remaining history, assessment data, and trends
before choosing the next intervention.
Question 8.
A planned nursing response is to keep needed items within reach use appropriate footwear
and assist with mobility as indicated. Which finding should the nurse connect most directly
with the reason for this intervention?
A. Medications and procedures require at least two approved client identifiers.
B. Fall prevention should be individualized to risk factors rather than relying on restraints.
C. Damaged cords wet equipment or malfunctioning devices can cause shock or fire.
D. Clients with impaired swallowing need positioning and diet modifications to reduce
aspiration.
Correct Answer: B. Fall prevention should be individualized to risk factors rather
than relying on restraints.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. The most characteristic cue or principle for Fall
prevention is fall prevention should be individualized to risk factors rather than relying on
restraints. Safety decisions should interrupt exposure or injury risk while preserving
appropriate infection-control and surveillance measures. The distractors describe findings
WITH ANSWERS AND EXPLANATIONS
Question 1.
A planned nursing response is to two qualified staff verify the client product unit number
blood type compatibility and expiration as required. Which finding should the nurse
connect most directly with the reason for this intervention?
A. Hand hygiene is the single most important routine action for reducing health-care
associated transmission.
B. Contaminated PPE should be removed to reduce self-contamination.
C. Blood products require strict identification and compatibility checks immediately before
administration.
D. Needles should be disposed of promptly in puncture-resistant sharps containers.
Correct Answer: C. Blood products require strict identification and compatibility
checks immediately before administration.
Explanation: The keyed option is the most direct response to the clinical problem in the
stem. The most characteristic cue or principle for Blood-product bedside verification is
blood products require strict identification and compatibility checks immediately before
administration. Safety decisions should interrupt exposure or injury risk while preserving
appropriate infection-control and surveillance measures. The distractors describe findings
associated with other nursing problems and therefore do not best identify the concept
being tested; the nurse should cluster this cue with the remaining history, assessment
data, and trends before choosing the next intervention.
Question 2.
The nurse anticipates the need to encourage talking reading and safe exploration rather
than screen-based stimulation. Which assessment pattern or principle should receive the
greatest weight?
A. Effective latch includes a wide-open mouth deep attachment and audible swallowing
without persistent nipple trauma.
B. Young infants show increasing social engagement and head control but still require full
support.
C. Many infants around six months begin sitting with support transferring objects and
responding socially.
D. Around one year many children pull to stand use simple gestures and may say a few
meaningful words.
Correct Answer: D. Around one year many children pull to stand use simple
gestures and may say a few meaningful words.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. The most characteristic cue or principle for
Twelve-month developmental expectations is around one year many children pull to stand
use simple gestures and may say a few meaningful words. Health-promotion care
emphasizes prevention, development, screening, immunization, anticipatory guidance,
,and early recognition of warning signs. The distractors describe findings associated with
other nursing problems and therefore do not best identify the concept being tested; the
nurse should cluster this cue with the remaining history, assessment data, and trends
before choosing the next intervention.
Question 3.
On a maternal-newborn unit, the nurse is preparing to correct volume chloride and
potassium deficits as ordered while treating the cause. Which assessment cue is most
consistent with the underlying problem?
A. MRI's strong magnetic field makes ferromagnetic implants and loose metal objects
hazardous.
B. Metabolic alkalosis features elevated bicarbonate and pH often from vomiting gastric
suction or diuretics.
C. Increasing pain numbness coolness delayed capillary refill or inability to move digits
may indicate impaired circulation or nerve compression.
D. Continuous bubbling in the water-seal chamber suggests an air leak somewhere in the
system or from the client.
Correct Answer: B. Metabolic alkalosis features elevated bicarbonate and pH
often from vomiting gastric suction or diuretics.
Explanation: This answer is the best match for the client data and the expected nursing
standard. The most characteristic cue or principle for Metabolic alkalosis is metabolic
alkalosis features elevated bicarbonate and pH often from vomiting gastric suction or
diuretics. Risk-reduction items depend on recognizing early complications, abnormal
trends, procedure-related hazards, and the need for timely escalation. The distractors
describe findings associated with other nursing problems and therefore do not best
identify the concept being tested; the nurse should cluster this cue with the remaining
history, assessment data, and trends before choosing the next intervention.
Question 4.
A 44-year-old client requires the nurse to the RN performs the admission assessment
before delegating routine care. Which cue most likely prompted this decision?
A. Initial comprehensive assessment requires RN clinical judgment.
B. Stable clients with predictable outcomes may receive routine medications from an LPN
according to scope.
C. Screening is most effective in private with direct nonjudgmental questions.
D. Verbal orders require accurate read-back and authentication according to policy.
Correct Answer: A. Initial comprehensive assessment requires RN clinical
judgment.
Explanation: The selected response is the most appropriate next step for the situation
presented. The most characteristic cue or principle for Initial nursing assessment is initial
comprehensive assessment requires RN clinical judgment. Management decisions must
account for acuity, scope of practice, client rights, communication, continuity, and RN
accountability. The distractors describe findings associated with other nursing problems
,and therefore do not best identify the concept being tested; the nurse should cluster this
cue with the remaining history, assessment data, and trends before choosing the next
intervention.
Question 5.
A 31-year-old client requires the nurse to check pulse and blood pressure before
administration and follow hold parameters. Which cue most likely prompted this decision?
A. ARBs lower blood pressure and can increase potassium and affect renal function.
B. NSAIDs can cause gastrointestinal bleeding kidney injury fluid retention and
cardiovascular risk.
C. Beta blockers reduce heart rate and blood pressure and can mask adrenergic symptoms
of hypoglycemia.
D. Rapid-acting insulin can cause hypoglycemia and is timed closely with carbohydrate
intake.
Correct Answer: C. Beta blockers reduce heart rate and blood pressure and can
mask adrenergic symptoms of hypoglycemia.
Explanation: The correct option most specifically addresses the safety or physiologic
issue described. The most characteristic cue or principle for Beta blockers is beta blockers
reduce heart rate and blood pressure and can mask adrenergic symptoms of
hypoglycemia. Medication decisions require attention to indication, dose, administration
safety, adverse effects, interactions, and response to therapy. The distractors describe
findings associated with other nursing problems and therefore do not best identify the
concept being tested; the nurse should cluster this cue with the remaining history,
assessment data, and trends before choosing the next intervention.
Question 6.
The nurse anticipates the need to do not administer feedings or medications until
placement has been verified according to policy. Which assessment pattern or principle
should receive the greatest weight?
A. Stage 3 pressure injury involves full-thickness skin loss with visible adipose tissue but
no exposed fascia muscle tendon or bone.
B. Enteral feeding safety includes tube-position verification per policy aspiration
precautions and appropriate head elevation.
C. Range-of-motion exercises preserve joint mobility and should be slow controlled and
within tolerance.
D. Initial feeding-tube placement is verified by an approved method before use and
external length is monitored thereafter.
Correct Answer: D. Initial feeding-tube placement is verified by an approved
method before use and external length is monitored thereafter.
Explanation: The selected response is the most appropriate next step for the situation
presented. The most characteristic cue or principle for Nasogastric tube placement is
initial feeding-tube placement is verified by an approved method before use and external
length is monitored thereafter. Basic-care decisions should preserve function, nutrition,
, elimination, mobility, skin integrity, comfort, and dignity without creating avoidable risk.
The distractors describe findings associated with other nursing problems and therefore do
not best identify the concept being tested; the nurse should cluster this cue with the
remaining history, assessment data, and trends before choosing the next intervention.
Question 7.
The care plan includes the response: monitor potassium creatinine and blood pressure
after initiation or dose changes. Which finding or principle would most strongly justify this
plan?
A. ARBs lower blood pressure and can increase potassium and affect renal function.
B. Isoniazid can cause hepatotoxicity and peripheral neuropathy and is often given with
pyridoxine.
C. Beta blockers reduce heart rate and blood pressure and can mask adrenergic symptoms
of hypoglycemia.
D. Benzodiazepines can cause sedation respiratory depression falls and dependence
especially with opioids or alcohol.
Correct Answer: A. ARBs lower blood pressure and can increase potassium and
affect renal function.
Explanation: The selected response is the most appropriate next step for the situation
presented. The most characteristic cue or principle for Angiotensin receptor blockers is
aRBs lower blood pressure and can increase potassium and affect renal function.
Medication decisions require attention to indication, dose, administration safety, adverse
effects, interactions, and response to therapy. The distractors describe findings associated
with other nursing problems and therefore do not best identify the concept being tested;
the nurse should cluster this cue with the remaining history, assessment data, and trends
before choosing the next intervention.
Question 8.
A planned nursing response is to keep needed items within reach use appropriate footwear
and assist with mobility as indicated. Which finding should the nurse connect most directly
with the reason for this intervention?
A. Medications and procedures require at least two approved client identifiers.
B. Fall prevention should be individualized to risk factors rather than relying on restraints.
C. Damaged cords wet equipment or malfunctioning devices can cause shock or fire.
D. Clients with impaired swallowing need positioning and diet modifications to reduce
aspiration.
Correct Answer: B. Fall prevention should be individualized to risk factors rather
than relying on restraints.
Explanation: Clinical judgment favors this response because it targets the identified
problem rather than a secondary concern. The most characteristic cue or principle for Fall
prevention is fall prevention should be individualized to risk factors rather than relying on
restraints. Safety decisions should interrupt exposure or injury risk while preserving
appropriate infection-control and surveillance measures. The distractors describe findings
