1
HESI RN Exit Exam Bundle –
Verified Questions & actual
Answer Scheme | Grade A+
Updated Version with
Rationales
Section 1: Patient Safety (50 Questions)
1. A client with a history of heart failure is admitted with shortness of breath. Which
assessment finding requires immediate intervention?
A. Blood pressure of 140/90 mmHg
B. Heart rate of 88 beats/min
C. Oxygen saturation of 88%
D. Respiratory rate of 20 breaths/min
Rationale: An oxygen saturation of 88% indicates hypoxemia, which can lead to tissue
hypoxia and requires immediate intervention, such as supplemental oxygen, to ensure
patient safety.
2. The nurse is caring for a client receiving a blood transfusion. Which symptom indicates a
potential transfusion reaction?
A. Fever and chills
B. Increased urine output
C. Decreased heart rate
D. Improved skin color
Rationale: Fever and chills are classic signs of a transfusion reaction, requiring
immediate cessation of the transfusion to prevent further complications.
3. A client with a new tracheostomy is at risk for aspiration. Which nursing action best
prevents this?
A. Encourage oral intake of thin liquids
B. Keep the head of the bed elevated at 30–45 degrees
C. Suction the tracheostomy every 8 hours
D. Place the client in a prone position
Rationale: Elevating the head of the bed reduces the risk of aspiration by promoting
proper alignment of the airway and facilitating swallowing.
, 2
4. (SATA) The nurse is implementing fall prevention strategies for an elderly client. Which
interventions are appropriate?
A. Ensure the bed is in the lowest position
B. Keep the call light within reach
C. Encourage the client to wear socks without non-slip soles
D. Provide adequate lighting in the room
Rationale: Keeping the bed low, ensuring access to the call light, and providing adequate
lighting reduce fall risk. Socks without non-slip soles increase the risk of slipping.
5. A client with a central venous catheter reports sudden chest pain and dyspnea. What is
the nurse’s priority action?
A. Administer pain medication
B. Assess for signs of air embolism
C. Flush the catheter with saline
D. Reposition the client
Rationale: Sudden chest pain and dyspnea may indicate an air embolism, a life-
threatening complication requiring immediate assessment and intervention.
6. A client is receiving heparin therapy. Which laboratory value should the nurse monitor
closely?
A. International normalized ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Prothrombin time (PT)
Rationale: Heparin’s therapeutic effect is monitored using aPTT to ensure safe
anticoagulation and prevent bleeding or clotting complications.
7. The nurse observes a client with a history of seizures having a tonic-clonic seizure.
Which action is the priority?
A. Protect the client from injury
B. Insert an oral airway
C. Restrain the client’s limbs
D. Administer lorazepam immediately
Rationale: Protecting the client from injury during a seizure is the priority to ensure
safety, followed by other interventions like medication administration.
8. A client with diabetes mellitus is receiving insulin. Which finding indicates
hypoglycemia?
A. Polyuria
B. Shakiness and diaphoresis
C. Kussmaul respirations
D. Warm, dry skin
Rationale: Shakiness and diaphoresis are hallmark signs of hypoglycemia, requiring
immediate intervention such as administering glucose.
9. (SATA) Which precautions are necessary for a client with methicillin-resistant
Staphylococcus aureus (MRSA)?
A. Wear gloves when entering the room
B. Use a dedicated stethoscope
C. Allow visitors without restrictions
D. Wear a gown for direct contact
, 3
Rationale: Contact precautions for MRSA include gloves, a dedicated stethoscope, and a
gown for direct contact. Unrestricted visitors can increase transmission risk.
10. A client with a new colostomy is at risk for skin breakdown. Which nursing intervention
is most effective?
A. Cleanse the stoma with alcohol-based solution
B. Ensure a proper-fitting ostomy appliance
C. Apply adhesive tape directly to the stoma
D. Change the appliance weekly
Rationale: A proper-fitting ostomy appliance prevents leakage and protects the
peristomal skin, reducing the risk of breakdown.
11. The nurse is preparing to administer a medication through a nasogastric tube. Which
action ensures patient safety?
A. Verify tube placement before administration
B. Crush all medications for easier administration
C. Administer the medication without flushing the tube
D. Use a 10 mL syringe for administration
Rationale: Verifying tube placement prevents medication administration into the lungs,
ensuring patient safety.
12. A client with a history of deep vein thrombosis is receiving warfarin. Which food should
the nurse advise the client to limit?
A. Apples
B. Spinach
C. Chicken
D. Rice
Rationale: Spinach is high in vitamin K, which can interfere with warfarin’s
anticoagulant effect, requiring dietary moderation.
13. The nurse is caring for a client with a pressure ulcer. Which intervention promotes wound
healing?
A. Cleanse the wound with hydrogen peroxide
B. Keep the wound bed moist
C. Apply a dry gauze dressing
D. Leave the wound open to air
Rationale: A moist wound environment promotes healing by facilitating cell migration
and preventing tissue desiccation.
14. (SATA) Which actions are appropriate when caring for a client with a suspected spinal
cord injury?
A. Immobilize the cervical spine
B. Turn the client every 2 hours
C. Log-roll the client during repositioning
D. Apply a cervical collar
Rationale: Immobilizing the spine, log-rolling, and applying a cervical collar prevent
further injury. Turning without stabilization risks exacerbating the injury.
15. A client is receiving chemotherapy and reports nausea. Which medication should the
nurse prepare to administer?
A. Ibuprofen
B. Ondansetron
, 4
C. Acetaminophen
D. Morphine
Rationale: Ondansetron is an antiemetic commonly used to manage chemotherapy-
induced nausea, promoting patient comfort and safety.
16. The nurse is assessing a client with a suspected urinary tract infection. Which symptom is
most concerning?
A. Frequency
B. Dysuria
C. Fever and confusion
D. Urgency
Rationale: Fever and confusion may indicate sepsis, a life-threatening complication
requiring immediate intervention.
17. A client with a history of asthma is experiencing wheezing. Which medication should the
nurse administer first?
A. Albuterol
B. Prednisone
C. Montelukast
D. Ipratropium
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute
asthma exacerbations to relieve bronchospasm.
18. The nurse is preparing to insert a urinary catheter. Which action ensures a sterile
technique?
A. Use clean gloves for insertion
B. Maintain a sterile field during the procedure
C. Cleanse the meatus with tap water
D. Reuse the catheter if it becomes contaminated
Rationale: Maintaining a sterile field prevents infection, a critical aspect of patient safety
during catheter insertion.
19. (SATA) Which interventions reduce the risk of ventilator-associated pneumonia?
A. Elevate the head of the bed 30–45 degrees
B. Perform oral care with chlorhexidine
C. Suction the trachea every 12 hours
D. Use a subglottic suctioning endotracheal tube
Rationale: Elevating the bed, using chlorhexidine for oral care, and subglottic suctioning
reduce aspiration and bacterial growth. Routine suctioning every 12 hours is insufficient.
20. A client with a history of liver failure is receiving lactulose. Which outcome indicates the
medication is effective?
A. Increased blood pressure
B. Two to three soft stools per day
C. Decreased urine output
D. Elevated ammonia levels
Rationale: Lactulose reduces ammonia levels in liver failure by promoting bowel
movements, with an expected outcome of 2–3 soft stools daily.
21. The nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic
test should the nurse anticipate?
A. Chest X-ray
HESI RN Exit Exam Bundle –
Verified Questions & actual
Answer Scheme | Grade A+
Updated Version with
Rationales
Section 1: Patient Safety (50 Questions)
1. A client with a history of heart failure is admitted with shortness of breath. Which
assessment finding requires immediate intervention?
A. Blood pressure of 140/90 mmHg
B. Heart rate of 88 beats/min
C. Oxygen saturation of 88%
D. Respiratory rate of 20 breaths/min
Rationale: An oxygen saturation of 88% indicates hypoxemia, which can lead to tissue
hypoxia and requires immediate intervention, such as supplemental oxygen, to ensure
patient safety.
2. The nurse is caring for a client receiving a blood transfusion. Which symptom indicates a
potential transfusion reaction?
A. Fever and chills
B. Increased urine output
C. Decreased heart rate
D. Improved skin color
Rationale: Fever and chills are classic signs of a transfusion reaction, requiring
immediate cessation of the transfusion to prevent further complications.
3. A client with a new tracheostomy is at risk for aspiration. Which nursing action best
prevents this?
A. Encourage oral intake of thin liquids
B. Keep the head of the bed elevated at 30–45 degrees
C. Suction the tracheostomy every 8 hours
D. Place the client in a prone position
Rationale: Elevating the head of the bed reduces the risk of aspiration by promoting
proper alignment of the airway and facilitating swallowing.
, 2
4. (SATA) The nurse is implementing fall prevention strategies for an elderly client. Which
interventions are appropriate?
A. Ensure the bed is in the lowest position
B. Keep the call light within reach
C. Encourage the client to wear socks without non-slip soles
D. Provide adequate lighting in the room
Rationale: Keeping the bed low, ensuring access to the call light, and providing adequate
lighting reduce fall risk. Socks without non-slip soles increase the risk of slipping.
5. A client with a central venous catheter reports sudden chest pain and dyspnea. What is
the nurse’s priority action?
A. Administer pain medication
B. Assess for signs of air embolism
C. Flush the catheter with saline
D. Reposition the client
Rationale: Sudden chest pain and dyspnea may indicate an air embolism, a life-
threatening complication requiring immediate assessment and intervention.
6. A client is receiving heparin therapy. Which laboratory value should the nurse monitor
closely?
A. International normalized ratio (INR)
B. Activated partial thromboplastin time (aPTT)
C. Platelet count
D. Prothrombin time (PT)
Rationale: Heparin’s therapeutic effect is monitored using aPTT to ensure safe
anticoagulation and prevent bleeding or clotting complications.
7. The nurse observes a client with a history of seizures having a tonic-clonic seizure.
Which action is the priority?
A. Protect the client from injury
B. Insert an oral airway
C. Restrain the client’s limbs
D. Administer lorazepam immediately
Rationale: Protecting the client from injury during a seizure is the priority to ensure
safety, followed by other interventions like medication administration.
8. A client with diabetes mellitus is receiving insulin. Which finding indicates
hypoglycemia?
A. Polyuria
B. Shakiness and diaphoresis
C. Kussmaul respirations
D. Warm, dry skin
Rationale: Shakiness and diaphoresis are hallmark signs of hypoglycemia, requiring
immediate intervention such as administering glucose.
9. (SATA) Which precautions are necessary for a client with methicillin-resistant
Staphylococcus aureus (MRSA)?
A. Wear gloves when entering the room
B. Use a dedicated stethoscope
C. Allow visitors without restrictions
D. Wear a gown for direct contact
, 3
Rationale: Contact precautions for MRSA include gloves, a dedicated stethoscope, and a
gown for direct contact. Unrestricted visitors can increase transmission risk.
10. A client with a new colostomy is at risk for skin breakdown. Which nursing intervention
is most effective?
A. Cleanse the stoma with alcohol-based solution
B. Ensure a proper-fitting ostomy appliance
C. Apply adhesive tape directly to the stoma
D. Change the appliance weekly
Rationale: A proper-fitting ostomy appliance prevents leakage and protects the
peristomal skin, reducing the risk of breakdown.
11. The nurse is preparing to administer a medication through a nasogastric tube. Which
action ensures patient safety?
A. Verify tube placement before administration
B. Crush all medications for easier administration
C. Administer the medication without flushing the tube
D. Use a 10 mL syringe for administration
Rationale: Verifying tube placement prevents medication administration into the lungs,
ensuring patient safety.
12. A client with a history of deep vein thrombosis is receiving warfarin. Which food should
the nurse advise the client to limit?
A. Apples
B. Spinach
C. Chicken
D. Rice
Rationale: Spinach is high in vitamin K, which can interfere with warfarin’s
anticoagulant effect, requiring dietary moderation.
13. The nurse is caring for a client with a pressure ulcer. Which intervention promotes wound
healing?
A. Cleanse the wound with hydrogen peroxide
B. Keep the wound bed moist
C. Apply a dry gauze dressing
D. Leave the wound open to air
Rationale: A moist wound environment promotes healing by facilitating cell migration
and preventing tissue desiccation.
14. (SATA) Which actions are appropriate when caring for a client with a suspected spinal
cord injury?
A. Immobilize the cervical spine
B. Turn the client every 2 hours
C. Log-roll the client during repositioning
D. Apply a cervical collar
Rationale: Immobilizing the spine, log-rolling, and applying a cervical collar prevent
further injury. Turning without stabilization risks exacerbating the injury.
15. A client is receiving chemotherapy and reports nausea. Which medication should the
nurse prepare to administer?
A. Ibuprofen
B. Ondansetron
, 4
C. Acetaminophen
D. Morphine
Rationale: Ondansetron is an antiemetic commonly used to manage chemotherapy-
induced nausea, promoting patient comfort and safety.
16. The nurse is assessing a client with a suspected urinary tract infection. Which symptom is
most concerning?
A. Frequency
B. Dysuria
C. Fever and confusion
D. Urgency
Rationale: Fever and confusion may indicate sepsis, a life-threatening complication
requiring immediate intervention.
17. A client with a history of asthma is experiencing wheezing. Which medication should the
nurse administer first?
A. Albuterol
B. Prednisone
C. Montelukast
D. Ipratropium
Rationale: Albuterol, a short-acting beta-agonist, is the first-line treatment for acute
asthma exacerbations to relieve bronchospasm.
18. The nurse is preparing to insert a urinary catheter. Which action ensures a sterile
technique?
A. Use clean gloves for insertion
B. Maintain a sterile field during the procedure
C. Cleanse the meatus with tap water
D. Reuse the catheter if it becomes contaminated
Rationale: Maintaining a sterile field prevents infection, a critical aspect of patient safety
during catheter insertion.
19. (SATA) Which interventions reduce the risk of ventilator-associated pneumonia?
A. Elevate the head of the bed 30–45 degrees
B. Perform oral care with chlorhexidine
C. Suction the trachea every 12 hours
D. Use a subglottic suctioning endotracheal tube
Rationale: Elevating the bed, using chlorhexidine for oral care, and subglottic suctioning
reduce aspiration and bacterial growth. Routine suctioning every 12 hours is insufficient.
20. A client with a history of liver failure is receiving lactulose. Which outcome indicates the
medication is effective?
A. Increased blood pressure
B. Two to three soft stools per day
C. Decreased urine output
D. Elevated ammonia levels
Rationale: Lactulose reduces ammonia levels in liver failure by promoting bowel
movements, with an expected outcome of 2–3 soft stools daily.
21. The nurse is caring for a client with a suspected pulmonary embolism. Which diagnostic
test should the nurse anticipate?
A. Chest X-ray
