Fall SemeSter 2025 | HeSI rN CompreHeNSIve
exIt exam Complete Study GuIde & HIGH-yIeld
NurSING revIew BuNdle | updated 2024–2025 HeSI
exIt ratIoNaleS, pHarmaColoGy, FuNdameNtalS,
med-SurG, materNIty, meNtal HealtH,
pedIatrICS, prIorIty NurSING INterveNtIoNS,
ClINICal JudGmeNt, CaSe SCeNarIoS & NClex-
Style maStery NoteS
Question 1:
Which of the following findings would be most concerning when assessing a patient
with heart failure?
A) Decreased urine output
B) Increased peripheral edema
C) Productive cough with clear sputum
D) Heart rate of 70 bpm
CORRECT OPTION: B) Increased peripheral edema
Rationale: Increased peripheral edema is a significant indicator of worsening heart
failure and fluid overload, signaling potential decompensation.
Question 2:
What is the priority nursing action for a patient experiencing a panic attack?
A) Administer an anxiolytic medication
B) Encourage the patient to talk about their feelings
C) Guide the patient through deep-breathing exercises
D) Call for psychiatric support
CORRECT OPTION: C) Guide the patient through deep-breathing exercises
Rationale: Guiding the patient through deep-breathing exercises helps to reduce
physiological symptoms of anxiety and promotes relaxation, which is crucial in
managing a panic attack.
Question 3:
A nurse is caring for a patient with a newly placed tracheostomy. What is the most
important initial intervention?
A) Suction the tracheostomy tube
B) Administer oxygen via the tracheostomy
,C) Ensure patency of the airway
D) Teach the patient about tube care
CORRECT OPTION: C) Ensure patency of the airway
Rationale: Ensuring patency of the airway is the priority to prevent hypoxia and
complications following the procedure.
Question 4:
What is the most appropriate nursing intervention for a patient diagnosed with diabetes
who is experiencing hypoglycemia?
A) Administer insulin immediately
B) Provide 15 grams of fast-acting carbohydrates
C) Encourage the patient to exercise
D) Prepare the patient for a glucose tolerance test
CORRECT OPTION: B) Provide 15 grams of fast-acting carbohydrates
Rationale: Administering fast-acting carbohydrates is the immediate treatment for
hypoglycemia and will quickly raise blood glucose levels.
Question 5:
Which of the following statements by the patient indicates a correct understanding of
the teaching regarding warfarin therapy?
A) “I can take any over-the-counter medications.”
B) “I will have regular blood tests to check my INR levels.”
C) “I should eat a diet high in vitamin K.”
D) “I don’t need to worry about any physical activities.”
CORRECT OPTION: B) “I will have regular blood tests to check my INR levels.”
Rationale: Regular monitoring of INR levels is crucial for patients on warfarin therapy to
maintain therapeutic efficacy and avoid complications.
Question 6:
A nurse is caring for a patient with a cervical spinal cord injury. What is the primary
assessment the nurse should perform?
A) Assess lung sounds
B) Monitor renal function
C) Assess motor and sensory function
D) Check for abdominal distension
CORRECT OPTION: C) Assess motor and sensory function
,Rationale: The primary assessment for a patient with a cervical spinal cord injury
involves evaluating motor and sensory function to determine the extent of neurological
impairment.
Question 7:
What is the most common complication of prolonged immobility?
A) Hypoglycemia
B) Hyperkalemia
C) Deep vein thrombosis (DVT)
D) Hypertension
CORRECT OPTION: C) Deep vein thrombosis (DVT)
Rationale: Prolonged immobility can lead to reduced venous return and increased risk
for DVT due to blood pooling in the lower extremities.
Question 8:
A patient presents with sudden onset chest pain and shortness of breath. What is the
first action the nurse should take?
A) Obtain a 12-lead ECG
B) Assess vital signs
C) Administer nitroglycerin
D) Place the patient in a supine position
CORRECT OPTION: B) Assess vital signs
Rationale: Assessing vital signs is crucial to determine the patient's hemodynamic
status and formulate an immediate plan of care.
Question 9:
Which lab result would the nurse expect to see in a patient with hypokalemia?
A) Elevated sodium level
B) Decreased hematocrit
C) Increased blood urea nitrogen (BUN)
D) Low potassium level
CORRECT OPTION: D) Low potassium level
Rationale: Hypokalemia is characterized by decreased serum potassium levels, which
can lead to various clinical manifestations.
, Question 10:
During medication administration, the nurse realizes they have given the wrong dose of
a medication. What is the nurse’s priority action?
A) Document the error
B) Inform the patient
C) Notify the healthcare provider
D) Reassess the patient's condition
CORRECT OPTION: C) Notify the healthcare provider
Rationale: The immediate priority is to notify the healthcare provider to assess the
situation and provide necessary interventions.
Question 11:
What is the best position for a patient experiencing respiratory distress?
A) Supine
B) Prone
C) Trendelenburg
D) High Fowler's
CORRECT OPTION: D) High Fowler's
Rationale: High Fowler's position facilitates optimal lung expansion and alleviates
respiratory distress.
Question 12:
A nurse is preparing a patient for discharge following a myocardial infarction. What
should the nurse include in the discharge teaching?
A) “You can resume all activities immediately.”
B) “You should avoid all physical activity for the next month.”
C) “Follow a low-sodium and heart-healthy diet.”
D) “You will no longer need to monitor your blood pressure.”
CORRECT OPTION: C) “Follow a low-sodium and heart-healthy diet.”
Rationale: Following discharge after a myocardial infarction, a heart-healthy diet is
essential for preventing further cardiovascular events.
Question 13:
exIt exam Complete Study GuIde & HIGH-yIeld
NurSING revIew BuNdle | updated 2024–2025 HeSI
exIt ratIoNaleS, pHarmaColoGy, FuNdameNtalS,
med-SurG, materNIty, meNtal HealtH,
pedIatrICS, prIorIty NurSING INterveNtIoNS,
ClINICal JudGmeNt, CaSe SCeNarIoS & NClex-
Style maStery NoteS
Question 1:
Which of the following findings would be most concerning when assessing a patient
with heart failure?
A) Decreased urine output
B) Increased peripheral edema
C) Productive cough with clear sputum
D) Heart rate of 70 bpm
CORRECT OPTION: B) Increased peripheral edema
Rationale: Increased peripheral edema is a significant indicator of worsening heart
failure and fluid overload, signaling potential decompensation.
Question 2:
What is the priority nursing action for a patient experiencing a panic attack?
A) Administer an anxiolytic medication
B) Encourage the patient to talk about their feelings
C) Guide the patient through deep-breathing exercises
D) Call for psychiatric support
CORRECT OPTION: C) Guide the patient through deep-breathing exercises
Rationale: Guiding the patient through deep-breathing exercises helps to reduce
physiological symptoms of anxiety and promotes relaxation, which is crucial in
managing a panic attack.
Question 3:
A nurse is caring for a patient with a newly placed tracheostomy. What is the most
important initial intervention?
A) Suction the tracheostomy tube
B) Administer oxygen via the tracheostomy
,C) Ensure patency of the airway
D) Teach the patient about tube care
CORRECT OPTION: C) Ensure patency of the airway
Rationale: Ensuring patency of the airway is the priority to prevent hypoxia and
complications following the procedure.
Question 4:
What is the most appropriate nursing intervention for a patient diagnosed with diabetes
who is experiencing hypoglycemia?
A) Administer insulin immediately
B) Provide 15 grams of fast-acting carbohydrates
C) Encourage the patient to exercise
D) Prepare the patient for a glucose tolerance test
CORRECT OPTION: B) Provide 15 grams of fast-acting carbohydrates
Rationale: Administering fast-acting carbohydrates is the immediate treatment for
hypoglycemia and will quickly raise blood glucose levels.
Question 5:
Which of the following statements by the patient indicates a correct understanding of
the teaching regarding warfarin therapy?
A) “I can take any over-the-counter medications.”
B) “I will have regular blood tests to check my INR levels.”
C) “I should eat a diet high in vitamin K.”
D) “I don’t need to worry about any physical activities.”
CORRECT OPTION: B) “I will have regular blood tests to check my INR levels.”
Rationale: Regular monitoring of INR levels is crucial for patients on warfarin therapy to
maintain therapeutic efficacy and avoid complications.
Question 6:
A nurse is caring for a patient with a cervical spinal cord injury. What is the primary
assessment the nurse should perform?
A) Assess lung sounds
B) Monitor renal function
C) Assess motor and sensory function
D) Check for abdominal distension
CORRECT OPTION: C) Assess motor and sensory function
,Rationale: The primary assessment for a patient with a cervical spinal cord injury
involves evaluating motor and sensory function to determine the extent of neurological
impairment.
Question 7:
What is the most common complication of prolonged immobility?
A) Hypoglycemia
B) Hyperkalemia
C) Deep vein thrombosis (DVT)
D) Hypertension
CORRECT OPTION: C) Deep vein thrombosis (DVT)
Rationale: Prolonged immobility can lead to reduced venous return and increased risk
for DVT due to blood pooling in the lower extremities.
Question 8:
A patient presents with sudden onset chest pain and shortness of breath. What is the
first action the nurse should take?
A) Obtain a 12-lead ECG
B) Assess vital signs
C) Administer nitroglycerin
D) Place the patient in a supine position
CORRECT OPTION: B) Assess vital signs
Rationale: Assessing vital signs is crucial to determine the patient's hemodynamic
status and formulate an immediate plan of care.
Question 9:
Which lab result would the nurse expect to see in a patient with hypokalemia?
A) Elevated sodium level
B) Decreased hematocrit
C) Increased blood urea nitrogen (BUN)
D) Low potassium level
CORRECT OPTION: D) Low potassium level
Rationale: Hypokalemia is characterized by decreased serum potassium levels, which
can lead to various clinical manifestations.
, Question 10:
During medication administration, the nurse realizes they have given the wrong dose of
a medication. What is the nurse’s priority action?
A) Document the error
B) Inform the patient
C) Notify the healthcare provider
D) Reassess the patient's condition
CORRECT OPTION: C) Notify the healthcare provider
Rationale: The immediate priority is to notify the healthcare provider to assess the
situation and provide necessary interventions.
Question 11:
What is the best position for a patient experiencing respiratory distress?
A) Supine
B) Prone
C) Trendelenburg
D) High Fowler's
CORRECT OPTION: D) High Fowler's
Rationale: High Fowler's position facilitates optimal lung expansion and alleviates
respiratory distress.
Question 12:
A nurse is preparing a patient for discharge following a myocardial infarction. What
should the nurse include in the discharge teaching?
A) “You can resume all activities immediately.”
B) “You should avoid all physical activity for the next month.”
C) “Follow a low-sodium and heart-healthy diet.”
D) “You will no longer need to monitor your blood pressure.”
CORRECT OPTION: C) “Follow a low-sodium and heart-healthy diet.”
Rationale: Following discharge after a myocardial infarction, a heart-healthy diet is
essential for preventing further cardiovascular events.
Question 13:
