HESI RN 2025 EXIT EXAM LATEST VERSION / ACTUAL AUTHENTIC EXAM
QUESTIONS AND ANSWERS PLUS RATIONALES GRADE A+ ASSURED(REAL DEAL)
Question 1
A nurse at a community clinic is preparing to administer medication to a client who is homeless.
The client states, "That's not the dose I usually take." What is the nurse's priority action?
A) Inform the client of their right to refuse the medication.
B) Explain to the client that dosages can sometimes change.
C) Withhold the medication until the dosage can be confirmed with the prescription.
D) Administer the medication and plan to verify the dose later.
Correct Answer: C) Withhold the medication until the dosage can be confirmed with the
prescription.
Rationale: The client's statement is a critical warning of a potential medication error. The
nurse's first priority is patient safety, which requires withholding the medication and verifying
the prescription before administration.
Question 2
A charge nurse on a neurological unit is making assignments. The team consists of one practical
nurse (PN) and three registered nurses (RNs). Which client is most appropriate to assign to the
PN?
A) A client with a subdural hematoma whose blood pressure changed from 150/80 mmHg to
170/60 mmHg.
B) A client with viral meningitis whose temperature changed from 101°F to 102°F.
C) A client with diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.
D) A client with myxedema whose blood pressure changed from 80/50 mmHg to 70/40 mmHg.
Correct Answer: B) A client with viral meningitis whose temperature changed from 101°F to
102°F.
Rationale: The client with viral meningitis is the most stable. A temperature increase is an
expected finding and can be managed by a PN. The other clients are exhibiting signs of
significant instability (widening pulse pressure, decreased GCS, severe hypotension) that
require the advanced assessment skills of an RN.
,Question 3
A client with pneumonia develops signs of septic shock and multi-organ failure. The sepsis
protocol is initiated. Which intervention is most important for the nurse to include in the plan of
care?
A) Maintain strict intake and output.
B) Keep the head of the bed raised to 45 degrees.
C) Assess for warmth of extremities.
D) Monitor blood glucose level.
Correct Answer: A) Maintain strict intake and output.
Rationale: In septic shock, massive vasodilation and capillary leak cause severe fluid shifts and
hypotension. Strict monitoring of intake and output is critical to guide fluid resuscitation and
assess renal perfusion, which is vital for preventing multi-organ failure.
Question 4
An adolescent client admitted for a suicide note becomes tearful and isolates in their room after
a team meeting. Which nursing intervention should the nurse perform first?
A) Allow the client to have some quiet time alone.
B) Explore the client's long-term goals for treatment.
C) Ask the treatment team what was discussed in the meeting.
D) Go to the client's room and ask what happened in the meeting.
Correct Answer: D) Go to the client's room and ask what happened in the meeting.
Rationale: The client is in distress. The nurse's immediate priority is to provide support and
assess the client's current emotional state. Going to the room and opening a line of
communication shows care and allows the nurse to assess for any immediate safety risks.
Question 5
The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once a day for a
client who weighs 154 pounds. The medication is available in a 25,000 units/mL vial. How many
milliliters should the nurse administer? (Round to the nearest tenth.)
A) 0.4 mL
B) 0.6 mL
,C) 1.2 mL
D) 1.4 mL
Correct Answer: B) 0.6 mL
Rationale: 1. Convert pounds to kg: 154 lb / 2.2 lb/kg = 70 kg. 2. Calculate the total dose: 70
kg * 200 units/kg = 14,000 units. 3. Calculate the volume to administer: (14,000 units / 25,000
units/mL) = 0.56 mL. 4. Round to the nearest tenth: 0.6 mL.
Question 6
A 49-year-old male with a history of smoking is admitted with flu-like symptoms, chest
congestion, and difficulty breathing. His oxygen saturation is 90% on room air. Which two orders
should the nurse complete first?
A) Sputum culture and start peripheral IV.
B) Start oxygen and place the client on a cardiorespiratory monitor.
C) Administer acetaminophen and obtain a chest x-ray.
D) Place the client on NPO status and start an IV infusion.
Correct Answer: B) Start oxygen and place the client on a cardiorespiratory monitor.
Rationale: According to ABC (Airway, Breathing, Circulation) priorities, addressing the client's
hypoxia (breathing) is the first priority. Starting oxygen and placing the client on a monitor to
assess their response and cardiac status are the most immediate and critical interventions.
Question 7
The provider orders oxygen at 3 L/minute via nasal cannula. Which items are essential for the
nurse to collect from the supply room to initiate this therapy? (Select all that apply.)
A) Humidifier bottle
B) Suction canister
C) Sterile water
D) Nasal cannula
E) Flow meter
Correct Answer: D, E) Nasal cannula, Flow meter.
Rationale: To administer oxygen via nasal cannula, the nurse needs the nasal cannula itself
and a flow meter to attach to the oxygen source on the wall and regulate the flow rate. A
, humidifier is recommended for flow rates greater than 4 L/min but is not essential to begin
therapy at 3 L/min.
Question 8
A client with pneumonia is anxious and restless. Vital signs are RR 28, O2 sat 90%, HR 101, BP
145/89. Capillary refill is 4 seconds. Which assessment findings are indicative of hypoxia? (Select
all that apply.)
A) Productive cough
B) Anxiousness and restlessness
C) Capillary refill of 4 seconds
D) Respiratory rate of 28 breaths/minute
E) Oxygen saturation of 90% on room air
Correct Answer: B, C, D, E) Anxiousness and restlessness; Capillary refill of 4 seconds;
Respiratory rate of 28 breaths/minute; Oxygen saturation of 90% on room air.
Rationale: Hypoxia manifests with neurological changes (anxiety, restlessness), poor
peripheral perfusion (prolonged capillary refill), and compensatory respiratory changes
(tachypnea). A low oxygen saturation is a direct measurement of hypoxia.
Question 9
To best promote breathing and gas exchange in a client with pneumonia and difficulty
breathing, the nurse should place the client in which position?
A) Supine
B) Prone
C) Semi-Fowler's
D) Side-lying
Correct Answer: C) Semi-Fowler's
Rationale: Placing the client in a Semi-Fowler's or High-Fowler's position allows for maximum
lung expansion by lowering the diaphragm, which decreases the work of breathing.
Question 10
A new graduate nurse is caring for a client who is now on an 8 L simple face mask. Which
QUESTIONS AND ANSWERS PLUS RATIONALES GRADE A+ ASSURED(REAL DEAL)
Question 1
A nurse at a community clinic is preparing to administer medication to a client who is homeless.
The client states, "That's not the dose I usually take." What is the nurse's priority action?
A) Inform the client of their right to refuse the medication.
B) Explain to the client that dosages can sometimes change.
C) Withhold the medication until the dosage can be confirmed with the prescription.
D) Administer the medication and plan to verify the dose later.
Correct Answer: C) Withhold the medication until the dosage can be confirmed with the
prescription.
Rationale: The client's statement is a critical warning of a potential medication error. The
nurse's first priority is patient safety, which requires withholding the medication and verifying
the prescription before administration.
Question 2
A charge nurse on a neurological unit is making assignments. The team consists of one practical
nurse (PN) and three registered nurses (RNs). Which client is most appropriate to assign to the
PN?
A) A client with a subdural hematoma whose blood pressure changed from 150/80 mmHg to
170/60 mmHg.
B) A client with viral meningitis whose temperature changed from 101°F to 102°F.
C) A client with diabetic ketoacidosis whose Glasgow Coma Scale score changed from 10 to 7.
D) A client with myxedema whose blood pressure changed from 80/50 mmHg to 70/40 mmHg.
Correct Answer: B) A client with viral meningitis whose temperature changed from 101°F to
102°F.
Rationale: The client with viral meningitis is the most stable. A temperature increase is an
expected finding and can be managed by a PN. The other clients are exhibiting signs of
significant instability (widening pulse pressure, decreased GCS, severe hypotension) that
require the advanced assessment skills of an RN.
,Question 3
A client with pneumonia develops signs of septic shock and multi-organ failure. The sepsis
protocol is initiated. Which intervention is most important for the nurse to include in the plan of
care?
A) Maintain strict intake and output.
B) Keep the head of the bed raised to 45 degrees.
C) Assess for warmth of extremities.
D) Monitor blood glucose level.
Correct Answer: A) Maintain strict intake and output.
Rationale: In septic shock, massive vasodilation and capillary leak cause severe fluid shifts and
hypotension. Strict monitoring of intake and output is critical to guide fluid resuscitation and
assess renal perfusion, which is vital for preventing multi-organ failure.
Question 4
An adolescent client admitted for a suicide note becomes tearful and isolates in their room after
a team meeting. Which nursing intervention should the nurse perform first?
A) Allow the client to have some quiet time alone.
B) Explore the client's long-term goals for treatment.
C) Ask the treatment team what was discussed in the meeting.
D) Go to the client's room and ask what happened in the meeting.
Correct Answer: D) Go to the client's room and ask what happened in the meeting.
Rationale: The client is in distress. The nurse's immediate priority is to provide support and
assess the client's current emotional state. Going to the room and opening a line of
communication shows care and allows the nurse to assess for any immediate safety risks.
Question 5
The healthcare provider prescribes dalteparin 200 units/kg subcutaneously once a day for a
client who weighs 154 pounds. The medication is available in a 25,000 units/mL vial. How many
milliliters should the nurse administer? (Round to the nearest tenth.)
A) 0.4 mL
B) 0.6 mL
,C) 1.2 mL
D) 1.4 mL
Correct Answer: B) 0.6 mL
Rationale: 1. Convert pounds to kg: 154 lb / 2.2 lb/kg = 70 kg. 2. Calculate the total dose: 70
kg * 200 units/kg = 14,000 units. 3. Calculate the volume to administer: (14,000 units / 25,000
units/mL) = 0.56 mL. 4. Round to the nearest tenth: 0.6 mL.
Question 6
A 49-year-old male with a history of smoking is admitted with flu-like symptoms, chest
congestion, and difficulty breathing. His oxygen saturation is 90% on room air. Which two orders
should the nurse complete first?
A) Sputum culture and start peripheral IV.
B) Start oxygen and place the client on a cardiorespiratory monitor.
C) Administer acetaminophen and obtain a chest x-ray.
D) Place the client on NPO status and start an IV infusion.
Correct Answer: B) Start oxygen and place the client on a cardiorespiratory monitor.
Rationale: According to ABC (Airway, Breathing, Circulation) priorities, addressing the client's
hypoxia (breathing) is the first priority. Starting oxygen and placing the client on a monitor to
assess their response and cardiac status are the most immediate and critical interventions.
Question 7
The provider orders oxygen at 3 L/minute via nasal cannula. Which items are essential for the
nurse to collect from the supply room to initiate this therapy? (Select all that apply.)
A) Humidifier bottle
B) Suction canister
C) Sterile water
D) Nasal cannula
E) Flow meter
Correct Answer: D, E) Nasal cannula, Flow meter.
Rationale: To administer oxygen via nasal cannula, the nurse needs the nasal cannula itself
and a flow meter to attach to the oxygen source on the wall and regulate the flow rate. A
, humidifier is recommended for flow rates greater than 4 L/min but is not essential to begin
therapy at 3 L/min.
Question 8
A client with pneumonia is anxious and restless. Vital signs are RR 28, O2 sat 90%, HR 101, BP
145/89. Capillary refill is 4 seconds. Which assessment findings are indicative of hypoxia? (Select
all that apply.)
A) Productive cough
B) Anxiousness and restlessness
C) Capillary refill of 4 seconds
D) Respiratory rate of 28 breaths/minute
E) Oxygen saturation of 90% on room air
Correct Answer: B, C, D, E) Anxiousness and restlessness; Capillary refill of 4 seconds;
Respiratory rate of 28 breaths/minute; Oxygen saturation of 90% on room air.
Rationale: Hypoxia manifests with neurological changes (anxiety, restlessness), poor
peripheral perfusion (prolonged capillary refill), and compensatory respiratory changes
(tachypnea). A low oxygen saturation is a direct measurement of hypoxia.
Question 9
To best promote breathing and gas exchange in a client with pneumonia and difficulty
breathing, the nurse should place the client in which position?
A) Supine
B) Prone
C) Semi-Fowler's
D) Side-lying
Correct Answer: C) Semi-Fowler's
Rationale: Placing the client in a Semi-Fowler's or High-Fowler's position allows for maximum
lung expansion by lowering the diaphragm, which decreases the work of breathing.
Question 10
A new graduate nurse is caring for a client who is now on an 8 L simple face mask. Which
