HESI Rn Exit Exam Retake V1 with NGN
Questions and Verified Rationalized Answers,
100% Guarantee Pass
Q001: 001
Type: NGN - Bowtie
Scenario Context: 68-year-old male, POD#2 CABG, on heparin 12 units/kg/h, aPTT 92
sec (control 30), no bleeding.
Question: Identify the priority lab abnormality and the nurse’s first action.
Options:
A. aPTT supratherapeutic → decrease heparin rate 50%
B. Platelet count drop → switch to bivalirudin
C. aPTT therapeutic → continue current rate
D. INR elevated → call for protamine
(Correct: A)
Rationale:
● Answer: A
● Why (2026 Rationalization): NCSBN CJMM Step 4 (generate solutions): aPTT
>80 sec (target 46-70) risks bleeding; 2026 ACCP recommends 50% rate
reduction.
, ● Errors: B premature without HIT labs; C misinterprets value; D protamine for
major bleeding only.
Q002: 002
Type: NGN - Extended Multiple Response
Scenario Context: Same patient (Q001); 2 h later aPTT 110 sec, gums ooze.
Question: Select all immediate nursing actions.
Options:
A. Stop heparin infusion
B. Obtain stat CBC
C. Start protamine 25 mg IV
D. Apply direct pressure to gums
E. Notify surgeon
F. Resume heparin at 75% rate
(Correct: A, B, D, E)
Rationale:
● Answer: A, B, D, E
● Why (2026 Rationalization): CJMM Step 5 (act): stop anticoagulant, assess
bleeding source, communicate.
● Errors: C requires provider order; F continues risk.
Q003: 003
, Type: Stand-Alone
Scenario Context: 38-week primigravida reports bright red vaginal bleeding, painless.
Question: Which action should the nurse take first?
Options:
A. Perform sterile vaginal exam
B. Apply fetal monitor
C. Start 18-gauge IV line
D. Check BP and HR
(Correct: D)
Rationale:
● Answer: D
● Why (2026 Rationalization): CJMM Step 1 (recognize cues): rule out hemorrhagic
shock before interventions.
● Errors: A may worsen placenta previa; B/C come after stability.
Q004: 004
Type: NGN - Matrix
Scenario Context: 5-year-old with asthma; peak-flow meter teaching.
Matrix Rows:
A. Green zone 100% personal best
B. Yellow zone 70%
Questions and Verified Rationalized Answers,
100% Guarantee Pass
Q001: 001
Type: NGN - Bowtie
Scenario Context: 68-year-old male, POD#2 CABG, on heparin 12 units/kg/h, aPTT 92
sec (control 30), no bleeding.
Question: Identify the priority lab abnormality and the nurse’s first action.
Options:
A. aPTT supratherapeutic → decrease heparin rate 50%
B. Platelet count drop → switch to bivalirudin
C. aPTT therapeutic → continue current rate
D. INR elevated → call for protamine
(Correct: A)
Rationale:
● Answer: A
● Why (2026 Rationalization): NCSBN CJMM Step 4 (generate solutions): aPTT
>80 sec (target 46-70) risks bleeding; 2026 ACCP recommends 50% rate
reduction.
, ● Errors: B premature without HIT labs; C misinterprets value; D protamine for
major bleeding only.
Q002: 002
Type: NGN - Extended Multiple Response
Scenario Context: Same patient (Q001); 2 h later aPTT 110 sec, gums ooze.
Question: Select all immediate nursing actions.
Options:
A. Stop heparin infusion
B. Obtain stat CBC
C. Start protamine 25 mg IV
D. Apply direct pressure to gums
E. Notify surgeon
F. Resume heparin at 75% rate
(Correct: A, B, D, E)
Rationale:
● Answer: A, B, D, E
● Why (2026 Rationalization): CJMM Step 5 (act): stop anticoagulant, assess
bleeding source, communicate.
● Errors: C requires provider order; F continues risk.
Q003: 003
, Type: Stand-Alone
Scenario Context: 38-week primigravida reports bright red vaginal bleeding, painless.
Question: Which action should the nurse take first?
Options:
A. Perform sterile vaginal exam
B. Apply fetal monitor
C. Start 18-gauge IV line
D. Check BP and HR
(Correct: D)
Rationale:
● Answer: D
● Why (2026 Rationalization): CJMM Step 1 (recognize cues): rule out hemorrhagic
shock before interventions.
● Errors: A may worsen placenta previa; B/C come after stability.
Q004: 004
Type: NGN - Matrix
Scenario Context: 5-year-old with asthma; peak-flow meter teaching.
Matrix Rows:
A. Green zone 100% personal best
B. Yellow zone 70%
