HESI PN Exit Exam 2 Questions and
Answers with Rationales Latest
Version 2026 Graded A+
1) A postpartum patient with severe hypertension has symptoms and is ordered
magnesium sulfate. Which assessment is required at regular intervals?
A. Deep tendon reflexes and respiratory rate
B. Only appetite and sleep patterns
C. Hair growth on scalp
D. Blood type confirmation again
Answer: A
Rationale:
• A: Correct—magnesium toxicity monitoring includes reflexes and RR.
• B: Not relevant to magnesium safety.
• C: Not relevant.
• D: Blood type confirmation is not the interval monitoring required here.
2) A patient has delirium. Which nursing approach is best?
A. Ignore the patient and avoid redirecting
B. Provide a calm environment and reorient as needed
C. Speak loudly and use complex medical terms
D. Restrain immediately to stop talking
Answer: B
Rationale:
• A: Delirium needs engagement/reorientation.
• B: Correct—calm, structured environment and reorientation reduce agitation.
• C: Speaking loudly and complex terms can worsen confusion.
• D: Restraints should be last resort and not immediate for “talking.”
,3) A patient with osteoarthritis is prescribed acetaminophen. Which statement is
correct teaching?
A. “Take extra doses if pain is severe, without concern.”
B. “Do not exceed the maximum daily dose to avoid liver injury.”
C. “It is safe to combine with any other pain medication freely.”
D. “You can skip doses because acetaminophen is ineffective.”
Answer: B
Rationale:
• A: Exceeding dose is dangerous (liver toxicity).
• B: Correct—maximum daily dose limits prevent hepatic injury.
• C: Many interactions exist—don’t “freely combine” without checking.
• D: Acetaminophen is effective for pain and should be taken as prescribed.
4) A nurse is preparing to administer an opioid. Which finding requires priority
intervention before giving the dose?
A. Respiratory rate 10/min.
B. Pain score 7/10.
C. Patient reports nausea.
D. BP 128/78.
Answer: A
• A: RR 10/min indicates respiratory depression risk—priority before opioid
administration.
• B: Pain matters, but safety comes first if respirations are dangerously low.
• C: Nausea can be managed; not an immediate safety blocker like RR.
• D: Normal BP supports stability but does not address respiratory status.
5) The nurse enters a room and finds a patient with a fire. What is the best
immediate action?
A. Run to get more oxygen equipment.
B. Activate the facility fire response and remove the patient from the source.
C. Apply more oxygen to maintain oxygen saturation.
D. Open doors to increase airflow to the room.
,Answer: B
• A: Oxygen near fire increases risk; do not run for more oxygen.
• B: Correct—follow fire protocol, remove patient from danger, shut off/contain if possible
per policy.
• C: Oxygen increases fire hazard.
• D: Opening doors can feed oxygen to the fire; follow protocol instead.
6) A nurse is caring for a patient with a new prescription for warfarin. Which
teaching is most accurate?
A. “Warfarin is used for immediate clot relief.”
B. “Avoid green leafy vegetables because they cause bleeding.”
C. “You will need regular INR monitoring.”
D. “You do not need to report bleeding or bruising.”
Answer: C
• A: Warfarin is not immediate; it takes days to become therapeutic.
• B: Green leafy vegetables contain vitamin K; consistent intake is needed—avoid sudden
changes, don’t fully eliminate unless instructed.
• C: Correct—INR monitoring is essential.
• D: Bleeding/bruising must be reported.
7) Which patient requires the nurse to check the glucose first?
A. A patient with diabetes who reports hunger and tremors.
B. A patient with an order for sliding-scale insulin.
C. A patient who is scheduled for a morning fingerstick.
D. A patient with no history of diabetes.
Answer: A
• A: Symptoms suggest hypoglycemia—glucose check immediately.
• B: Still important, but symptoms are acute priority.
• C: Scheduled checks are routine; treat symptoms first if present.
• D: No diabetes history means lower risk, not immediate need.
8) A nurse is prioritizing care. Which task should be performed first?
, A. Reassess a patient’s pain after medication.
B. Take a blood glucose on a patient with insulin due.
C. Assess a patient with BP 86/50 and decreased LOC.
D. Document intake/output for the shift.
Answer: C
• A: Important, but not as immediately unsafe as unstable vitals.
• B: Routine safety task; but unstable LOC/BP is higher acuity.
• C: Hypotension with decreased LOC may indicate shock—highest priority.
• D: Documentation is not first when a patient is unstable.
9) A patient’s lab work shows creatinine rising. Which nursing action is
appropriate for a medication that is renally cleared?
A. Give the dose as usual with no adjustments.
B. Continue the medication and ignore lab changes.
C. Notify provider/pharmacist to evaluate renal dosing.
D. Stop the medication immediately without orders.
Answer: C
• A: Renal dosing often changes with impaired function.
• B: Lab changes must be acted upon.
• C: Correct—renal adjustment must be ordered/verified.
• D: Nurses generally do not unilaterally stop; coordinate/notify for orders.
10) A nurse is teaching a patient about anticoagulants. Which statement
indicates correct understanding?
A. “I should take aspirin daily to prevent bleeding.”
B. “I should avoid activities that could cause injury.”
C. “I can stop the medication if I feel better.”
D. “I don’t need to report dark urine.”
Answer: B
• A: Aspirin increases bleeding risk unless specifically prescribed; incorrect teaching.
• B: Correct—reduce injury risk (falls, sharp injuries).
• C: Anticoagulants should not be stopped without provider direction.
• D: Dark urine could indicate bleeding—report.
Answers with Rationales Latest
Version 2026 Graded A+
1) A postpartum patient with severe hypertension has symptoms and is ordered
magnesium sulfate. Which assessment is required at regular intervals?
A. Deep tendon reflexes and respiratory rate
B. Only appetite and sleep patterns
C. Hair growth on scalp
D. Blood type confirmation again
Answer: A
Rationale:
• A: Correct—magnesium toxicity monitoring includes reflexes and RR.
• B: Not relevant to magnesium safety.
• C: Not relevant.
• D: Blood type confirmation is not the interval monitoring required here.
2) A patient has delirium. Which nursing approach is best?
A. Ignore the patient and avoid redirecting
B. Provide a calm environment and reorient as needed
C. Speak loudly and use complex medical terms
D. Restrain immediately to stop talking
Answer: B
Rationale:
• A: Delirium needs engagement/reorientation.
• B: Correct—calm, structured environment and reorientation reduce agitation.
• C: Speaking loudly and complex terms can worsen confusion.
• D: Restraints should be last resort and not immediate for “talking.”
,3) A patient with osteoarthritis is prescribed acetaminophen. Which statement is
correct teaching?
A. “Take extra doses if pain is severe, without concern.”
B. “Do not exceed the maximum daily dose to avoid liver injury.”
C. “It is safe to combine with any other pain medication freely.”
D. “You can skip doses because acetaminophen is ineffective.”
Answer: B
Rationale:
• A: Exceeding dose is dangerous (liver toxicity).
• B: Correct—maximum daily dose limits prevent hepatic injury.
• C: Many interactions exist—don’t “freely combine” without checking.
• D: Acetaminophen is effective for pain and should be taken as prescribed.
4) A nurse is preparing to administer an opioid. Which finding requires priority
intervention before giving the dose?
A. Respiratory rate 10/min.
B. Pain score 7/10.
C. Patient reports nausea.
D. BP 128/78.
Answer: A
• A: RR 10/min indicates respiratory depression risk—priority before opioid
administration.
• B: Pain matters, but safety comes first if respirations are dangerously low.
• C: Nausea can be managed; not an immediate safety blocker like RR.
• D: Normal BP supports stability but does not address respiratory status.
5) The nurse enters a room and finds a patient with a fire. What is the best
immediate action?
A. Run to get more oxygen equipment.
B. Activate the facility fire response and remove the patient from the source.
C. Apply more oxygen to maintain oxygen saturation.
D. Open doors to increase airflow to the room.
,Answer: B
• A: Oxygen near fire increases risk; do not run for more oxygen.
• B: Correct—follow fire protocol, remove patient from danger, shut off/contain if possible
per policy.
• C: Oxygen increases fire hazard.
• D: Opening doors can feed oxygen to the fire; follow protocol instead.
6) A nurse is caring for a patient with a new prescription for warfarin. Which
teaching is most accurate?
A. “Warfarin is used for immediate clot relief.”
B. “Avoid green leafy vegetables because they cause bleeding.”
C. “You will need regular INR monitoring.”
D. “You do not need to report bleeding or bruising.”
Answer: C
• A: Warfarin is not immediate; it takes days to become therapeutic.
• B: Green leafy vegetables contain vitamin K; consistent intake is needed—avoid sudden
changes, don’t fully eliminate unless instructed.
• C: Correct—INR monitoring is essential.
• D: Bleeding/bruising must be reported.
7) Which patient requires the nurse to check the glucose first?
A. A patient with diabetes who reports hunger and tremors.
B. A patient with an order for sliding-scale insulin.
C. A patient who is scheduled for a morning fingerstick.
D. A patient with no history of diabetes.
Answer: A
• A: Symptoms suggest hypoglycemia—glucose check immediately.
• B: Still important, but symptoms are acute priority.
• C: Scheduled checks are routine; treat symptoms first if present.
• D: No diabetes history means lower risk, not immediate need.
8) A nurse is prioritizing care. Which task should be performed first?
, A. Reassess a patient’s pain after medication.
B. Take a blood glucose on a patient with insulin due.
C. Assess a patient with BP 86/50 and decreased LOC.
D. Document intake/output for the shift.
Answer: C
• A: Important, but not as immediately unsafe as unstable vitals.
• B: Routine safety task; but unstable LOC/BP is higher acuity.
• C: Hypotension with decreased LOC may indicate shock—highest priority.
• D: Documentation is not first when a patient is unstable.
9) A patient’s lab work shows creatinine rising. Which nursing action is
appropriate for a medication that is renally cleared?
A. Give the dose as usual with no adjustments.
B. Continue the medication and ignore lab changes.
C. Notify provider/pharmacist to evaluate renal dosing.
D. Stop the medication immediately without orders.
Answer: C
• A: Renal dosing often changes with impaired function.
• B: Lab changes must be acted upon.
• C: Correct—renal adjustment must be ordered/verified.
• D: Nurses generally do not unilaterally stop; coordinate/notify for orders.
10) A nurse is teaching a patient about anticoagulants. Which statement
indicates correct understanding?
A. “I should take aspirin daily to prevent bleeding.”
B. “I should avoid activities that could cause injury.”
C. “I can stop the medication if I feel better.”
D. “I don’t need to report dark urine.”
Answer: B
• A: Aspirin increases bleeding risk unless specifically prescribed; incorrect teaching.
• B: Correct—reduce injury risk (falls, sharp injuries).
• C: Anticoagulants should not be stopped without provider direction.
• D: Dark urine could indicate bleeding—report.
