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EXIT HESI - COMPREHENSIVE EXAM
A PRACTICE QUESTIONS AND
ANSWERS A+
Section 1: Management of Care & Prioritization
(Questions 1–10)
1. A client in labor states, "I think my water just broke!" The nurse
notes that the umbilical cord is on the perineum. What action should
the nurse perform first?
A. Administer oxygen via face mask
B. Place the client in Trendelenburg
C. Notify the operating room team
D. Administer a fluid bolus of 500 ml
Correct Answer: B
Rationale: A prolapsed umbilical cord is an obstetric emergency. The
nurse's first action is to position the client in Trendelenburg or knee-
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chest position to relieve pressure on the cord and maintain fetal
perfusion . (A), (C), and (D) are important interventions but are not the
first priority—positioning the client to relieve cord compression takes
precedence.
2. The nurse is assigned to care for four clients. Which client should the
nurse assess first?
A. A client with COPD who has an oxygen saturation of 92% on 2L nasal
cannula
B. A client with heart failure reporting increased shortness of breath
when lying flat
C. A client with diabetes whose blood glucose is 180 mg/dL before
lunch
D. A client with osteoarthritis reporting pain at 6/10 in the right knee
Correct Answer: B
Rationale: The client with heart failure reporting orthopnea (shortness
of breath when lying flat) is showing signs of worsening heart failure
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and potential pulmonary edema, which requires immediate assessment
. (A) has an acceptable oxygen saturation for COPD. (C) has a glucose
level that requires intervention but is not immediately life-threatening.
(D) has chronic pain that is important but not the priority.
3. Select All That Apply: Which tasks are appropriate for the RN to
delegate to an unlicensed assistive personnel (UAP)?
A. Assisting a stable client with activities of daily living (bathing,
feeding)
B. Obtaining vital signs on stable clients
C. Assessing a client's pain level after medication administration
D. Administering oral medications to stable clients
E. Ambulating a stable client to the bathroom
Correct Answers: A, B, E
Rationale: Appropriate delegation to UAP includes assisting with ADLs
(A), obtaining vital signs on stable clients (B), and ambulating stable
clients (E) . Assessment of pain (C) and medication administration (D)
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require licensed nursing judgment and cannot be delegated. The Five
Rights of Delegation guide safe delegation practices.
4. A nurse is using the nursing process to care for a patient with a new
diagnosis of hypertension. Place the steps in the correct order (1 = first,
5 = last).
A. Assess the patient's current blood pressure, medications, and
lifestyle habits
B. Diagnose the patient with "Ineffective health maintenance related to
lack of knowledge"
C. Plan interventions including medication education, DASH diet, and
exercise counseling
D. Implement the planned interventions
E. Evaluate the patient's response to interventions
Correct Answer: A → B → C → D → E
Rationale: The nursing process is a systematic five-step framework:
Assessment (A), Diagnosis (B), Planning (C), Implementation (D), and
EXIT HESI - COMPREHENSIVE EXAM
A PRACTICE QUESTIONS AND
ANSWERS A+
Section 1: Management of Care & Prioritization
(Questions 1–10)
1. A client in labor states, "I think my water just broke!" The nurse
notes that the umbilical cord is on the perineum. What action should
the nurse perform first?
A. Administer oxygen via face mask
B. Place the client in Trendelenburg
C. Notify the operating room team
D. Administer a fluid bolus of 500 ml
Correct Answer: B
Rationale: A prolapsed umbilical cord is an obstetric emergency. The
nurse's first action is to position the client in Trendelenburg or knee-
,2|Page
chest position to relieve pressure on the cord and maintain fetal
perfusion . (A), (C), and (D) are important interventions but are not the
first priority—positioning the client to relieve cord compression takes
precedence.
2. The nurse is assigned to care for four clients. Which client should the
nurse assess first?
A. A client with COPD who has an oxygen saturation of 92% on 2L nasal
cannula
B. A client with heart failure reporting increased shortness of breath
when lying flat
C. A client with diabetes whose blood glucose is 180 mg/dL before
lunch
D. A client with osteoarthritis reporting pain at 6/10 in the right knee
Correct Answer: B
Rationale: The client with heart failure reporting orthopnea (shortness
of breath when lying flat) is showing signs of worsening heart failure
,3|Page
and potential pulmonary edema, which requires immediate assessment
. (A) has an acceptable oxygen saturation for COPD. (C) has a glucose
level that requires intervention but is not immediately life-threatening.
(D) has chronic pain that is important but not the priority.
3. Select All That Apply: Which tasks are appropriate for the RN to
delegate to an unlicensed assistive personnel (UAP)?
A. Assisting a stable client with activities of daily living (bathing,
feeding)
B. Obtaining vital signs on stable clients
C. Assessing a client's pain level after medication administration
D. Administering oral medications to stable clients
E. Ambulating a stable client to the bathroom
Correct Answers: A, B, E
Rationale: Appropriate delegation to UAP includes assisting with ADLs
(A), obtaining vital signs on stable clients (B), and ambulating stable
clients (E) . Assessment of pain (C) and medication administration (D)
, 4|Page
require licensed nursing judgment and cannot be delegated. The Five
Rights of Delegation guide safe delegation practices.
4. A nurse is using the nursing process to care for a patient with a new
diagnosis of hypertension. Place the steps in the correct order (1 = first,
5 = last).
A. Assess the patient's current blood pressure, medications, and
lifestyle habits
B. Diagnose the patient with "Ineffective health maintenance related to
lack of knowledge"
C. Plan interventions including medication education, DASH diet, and
exercise counseling
D. Implement the planned interventions
E. Evaluate the patient's response to interventions
Correct Answer: A → B → C → D → E
Rationale: The nursing process is a systematic five-step framework:
Assessment (A), Diagnosis (B), Planning (C), Implementation (D), and
