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HESI Exit Exam V2 (2025) | 200
NCLEX-Style Questions with
Rationales | Nursing Test Prep PDF
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Question 1
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A nurse enters the room of a client on contact precautions for Clostridioides difficile (C.
difficile). Which action is most appropriate before exiting the room?
A. Remove gloves and gown, then use alcohol-based hand rub
B. Remove gown, wash hands with soap and water, then remove gloves
C. Remove gloves and gown, then wash hands with soap and water
D. Remove gloves, use alcohol-based rub, and then remove gown
✔ Correct Answer: C
Rationale: C. difficile spores are resistant to alcohol. Soap and water is the only effective
method for hand hygiene after care. Gloves (most contaminated) are removed first, followed
by the gown. Proper PPE removal prevents cross-contamination.
Question 2
A client receiving IV morphine for pain becomes drowsy and has a respiratory rate of 8
breaths/min. What is the nurse’s priority action?
A. Notify the healthcare provider
B. Stop the morphine infusion
C. Administer naloxone
D. Apply oxygen via nasal cannula
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✔ Correct Answer: C
Rationale: A respiratory rate of 8 indicates opioid-induced respiratory depression. Naloxone
is the reversal agent and should be administered immediately. Other actions may follow but
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are not first priority.
Question 3
A nurse prepares to administer furosemide IV push to a client with heart failure. Which
electrolyte imbalance should the nurse monitor closely?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypophosphatemia
✔ Correct Answer: C
Rationale: Furosemide is a loop diuretic that increases urinary excretion of potassium,
risking hypokalemia. Monitor K+ levels to prevent cardiac dysrhythmias.
Question 4
A client is prescribed warfarin. Which instruction is most important to include in discharge
teaching?
A. Eat more leafy green vegetables
B. Take aspirin for pain instead of ibuprofen
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C. Use a soft-bristled toothbrush
D. Increase fluid intake to prevent constipation
Page | 4 ✔ Correct Answer: C
Rationale: Warfarin increases bleeding risk. A soft-bristled toothbrush reduces trauma to
gums. Leafy greens contain vitamin K and should be kept consistent, not increased.
Question 5
A 28-week pregnant client is receiving magnesium sulfate for preeclampsia. Which finding
requires immediate intervention?
A. Patellar reflex 2+
B. Respiratory rate of 10
C. Warm sensation during infusion
D. Urine output of 40 mL/hr
✔ Correct Answer: B
Rationale: Magnesium toxicity can cause respiratory depression. A rate <12 is critical.
Normal patellar reflex and urine output are acceptable. Warmth is expected.
Question 6
A client has a chest tube with continuous bubbling in the water seal chamber. What does this
indicate?
Page | 1
HESI Exit Exam V2 (2025) | 200
NCLEX-Style Questions with
Rationales | Nursing Test Prep PDF
, 2
Question 1
Page | 2
A nurse enters the room of a client on contact precautions for Clostridioides difficile (C.
difficile). Which action is most appropriate before exiting the room?
A. Remove gloves and gown, then use alcohol-based hand rub
B. Remove gown, wash hands with soap and water, then remove gloves
C. Remove gloves and gown, then wash hands with soap and water
D. Remove gloves, use alcohol-based rub, and then remove gown
✔ Correct Answer: C
Rationale: C. difficile spores are resistant to alcohol. Soap and water is the only effective
method for hand hygiene after care. Gloves (most contaminated) are removed first, followed
by the gown. Proper PPE removal prevents cross-contamination.
Question 2
A client receiving IV morphine for pain becomes drowsy and has a respiratory rate of 8
breaths/min. What is the nurse’s priority action?
A. Notify the healthcare provider
B. Stop the morphine infusion
C. Administer naloxone
D. Apply oxygen via nasal cannula
, 3
✔ Correct Answer: C
Rationale: A respiratory rate of 8 indicates opioid-induced respiratory depression. Naloxone
is the reversal agent and should be administered immediately. Other actions may follow but
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are not first priority.
Question 3
A nurse prepares to administer furosemide IV push to a client with heart failure. Which
electrolyte imbalance should the nurse monitor closely?
A. Hypercalcemia
B. Hypernatremia
C. Hypokalemia
D. Hypophosphatemia
✔ Correct Answer: C
Rationale: Furosemide is a loop diuretic that increases urinary excretion of potassium,
risking hypokalemia. Monitor K+ levels to prevent cardiac dysrhythmias.
Question 4
A client is prescribed warfarin. Which instruction is most important to include in discharge
teaching?
A. Eat more leafy green vegetables
B. Take aspirin for pain instead of ibuprofen
, 4
C. Use a soft-bristled toothbrush
D. Increase fluid intake to prevent constipation
Page | 4 ✔ Correct Answer: C
Rationale: Warfarin increases bleeding risk. A soft-bristled toothbrush reduces trauma to
gums. Leafy greens contain vitamin K and should be kept consistent, not increased.
Question 5
A 28-week pregnant client is receiving magnesium sulfate for preeclampsia. Which finding
requires immediate intervention?
A. Patellar reflex 2+
B. Respiratory rate of 10
C. Warm sensation during infusion
D. Urine output of 40 mL/hr
✔ Correct Answer: B
Rationale: Magnesium toxicity can cause respiratory depression. A rate <12 is critical.
Normal patellar reflex and urine output are acceptable. Warmth is expected.
Question 6
A client has a chest tube with continuous bubbling in the water seal chamber. What does this
indicate?
