HESI PN Exit Exam 2 Questions and
Answers with Rationales Latest
Version 2026 Top Rated
1) A nurse is caring for a postoperative patient at risk for falls. Which
intervention is most effective?
A. Keep the bed in the highest position.
B. Ensure call light and personal items are within reach.
C. Ask the patient to walk independently immediately after surgery.
D. Raise side rails only if the patient asks.
Answer: B
Rationale (all options):
• A: High bed position increases injury severity if a fall occurs; not best practice for fall
prevention.
• B: Call light and items within reach reduce delay in getting assistance—this is a key fall-
prevention strategy.
• C: Early independent ambulation without assessment/support after surgery increases fall
risk (especially with pain meds/sedation).
• D: Side rail use should follow policy and safety standards; not the primary strategy and
not based solely on patient request.
2) Which action best demonstrates proper hand hygiene?
A. Wearing gloves instead of washing hands.
B. Using hand sanitizer only when hands look clean.
C. Washing hands with soap and water after caring for a patient with diarrhea.
D. Rubbing hands briefly for a few seconds.
Answer: C
• A: Gloves do not replace hand hygiene; handwashing is still required.
• B: Hand sanitizer may not be effective against all pathogens (diarrhea/known GI illness
often requires soap/water).
• C: Correct—soap and water are recommended when caring for patients with diarrhea
(potentially more resistant organisms).
, • D: Inadequate contact time reduces effectiveness.
3) A patient is receiving oxygen by nasal cannula. Which patient statement
indicates correct understanding?
A. “This is only for people with severe breathing problems.”
B. “I should keep the nasal cannula in place all day.”
C. “I may experience dryness in my nose and throat.”
D. “I don’t need to monitor my breathing while on oxygen.”
Answer: C
• A: Oxygen can be prescribed for various conditions, not only “severe.”
• B: Use must follow orders; some patients require scheduled oxygen, not necessarily “all
day.”
• C: Nasal cannula can cause dryness; patients may need humidification or saline per plan.
• D: Patients should monitor symptoms and report increased work of breathing.
4) A nurse is preparing to administer an opioid. Which finding requires priority
intervention before giving the dose?
A. Respiratory rate 10/min.
B. Pain score 7/10.
C. Patient reports nausea.
D. BP 128/78.
Answer: A
• A: RR 10/min indicates respiratory depression risk—priority before opioid
administration.
• B: Pain matters, but safety comes first if respirations are dangerously low.
• C: Nausea can be managed; not an immediate safety blocker like RR.
• D: Normal BP supports stability but does not address respiratory status.
5) The nurse enters a room and finds a patient with a fire. What is the best
immediate action?
A. Run to get more oxygen equipment.
B. Activate the facility fire response and remove the patient from the source.
,C. Apply more oxygen to maintain oxygen saturation.
D. Open doors to increase airflow to the room.
Answer: B
• A: Oxygen near fire increases risk; do not run for more oxygen.
• B: Correct—follow fire protocol, remove patient from danger, shut off/contain if possible
per policy.
• C: Oxygen increases fire hazard.
• D: Opening doors can feed oxygen to the fire; follow protocol instead.
6) A nurse is caring for a patient with a new prescription for warfarin. Which
teaching is most accurate?
A. “Warfarin is used for immediate clot relief.”
B. “Avoid green leafy vegetables because they cause bleeding.”
C. “You will need regular INR monitoring.”
D. “You do not need to report bleeding or bruising.”
Answer: C
• A: Warfarin is not immediate; it takes days to become therapeutic.
• B: Green leafy vegetables contain vitamin K; consistent intake is needed—avoid sudden
changes, don’t fully eliminate unless instructed.
• C: Correct—INR monitoring is essential.
• D: Bleeding/bruising must be reported.
7) Which patient requires the nurse to check the glucose first?
A. A patient with diabetes who reports hunger and tremors.
B. A patient with an order for sliding-scale insulin.
C. A patient who is scheduled for a morning fingerstick.
D. A patient with no history of diabetes.
Answer: A
• A: Symptoms suggest hypoglycemia—glucose check immediately.
• B: Still important, but symptoms are acute priority.
• C: Scheduled checks are routine; treat symptoms first if present.
• D: No diabetes history means lower risk, not immediate need.
, 8) A nurse is prioritizing care. Which task should be performed first?
A. Reassess a patient’s pain after medication.
B. Take a blood glucose on a patient with insulin due.
C. Assess a patient with BP 86/50 and decreased LOC.
D. Document intake/output for the shift.
Answer: C
• A: Important, but not as immediately unsafe as unstable vitals.
• B: Routine safety task; but unstable LOC/BP is higher acuity.
• C: Hypotension with decreased LOC may indicate shock—highest priority.
• D: Documentation is not first when a patient is unstable.
9) A patient’s lab work shows creatinine rising. Which nursing action is
appropriate for a medication that is renally cleared?
A. Give the dose as usual with no adjustments.
B. Continue the medication and ignore lab changes.
C. Notify provider/pharmacist to evaluate renal dosing.
D. Stop the medication immediately without orders.
Answer: C
• A: Renal dosing often changes with impaired function.
• B: Lab changes must be acted upon.
• C: Correct—renal adjustment must be ordered/verified.
• D: Nurses generally do not unilaterally stop; coordinate/notify for orders.
10) A nurse is teaching a patient about anticoagulants. Which statement
indicates correct understanding?
A. “I should take aspirin daily to prevent bleeding.”
B. “I should avoid activities that could cause injury.”
C. “I can stop the medication if I feel better.”
D. “I don’t need to report dark urine.”
Answer: B
• A: Aspirin increases bleeding risk unless specifically prescribed; incorrect teaching.
• B: Correct—reduce injury risk (falls, sharp injuries).
• C: Anticoagulants should not be stopped without provider direction.
Answers with Rationales Latest
Version 2026 Top Rated
1) A nurse is caring for a postoperative patient at risk for falls. Which
intervention is most effective?
A. Keep the bed in the highest position.
B. Ensure call light and personal items are within reach.
C. Ask the patient to walk independently immediately after surgery.
D. Raise side rails only if the patient asks.
Answer: B
Rationale (all options):
• A: High bed position increases injury severity if a fall occurs; not best practice for fall
prevention.
• B: Call light and items within reach reduce delay in getting assistance—this is a key fall-
prevention strategy.
• C: Early independent ambulation without assessment/support after surgery increases fall
risk (especially with pain meds/sedation).
• D: Side rail use should follow policy and safety standards; not the primary strategy and
not based solely on patient request.
2) Which action best demonstrates proper hand hygiene?
A. Wearing gloves instead of washing hands.
B. Using hand sanitizer only when hands look clean.
C. Washing hands with soap and water after caring for a patient with diarrhea.
D. Rubbing hands briefly for a few seconds.
Answer: C
• A: Gloves do not replace hand hygiene; handwashing is still required.
• B: Hand sanitizer may not be effective against all pathogens (diarrhea/known GI illness
often requires soap/water).
• C: Correct—soap and water are recommended when caring for patients with diarrhea
(potentially more resistant organisms).
, • D: Inadequate contact time reduces effectiveness.
3) A patient is receiving oxygen by nasal cannula. Which patient statement
indicates correct understanding?
A. “This is only for people with severe breathing problems.”
B. “I should keep the nasal cannula in place all day.”
C. “I may experience dryness in my nose and throat.”
D. “I don’t need to monitor my breathing while on oxygen.”
Answer: C
• A: Oxygen can be prescribed for various conditions, not only “severe.”
• B: Use must follow orders; some patients require scheduled oxygen, not necessarily “all
day.”
• C: Nasal cannula can cause dryness; patients may need humidification or saline per plan.
• D: Patients should monitor symptoms and report increased work of breathing.
4) A nurse is preparing to administer an opioid. Which finding requires priority
intervention before giving the dose?
A. Respiratory rate 10/min.
B. Pain score 7/10.
C. Patient reports nausea.
D. BP 128/78.
Answer: A
• A: RR 10/min indicates respiratory depression risk—priority before opioid
administration.
• B: Pain matters, but safety comes first if respirations are dangerously low.
• C: Nausea can be managed; not an immediate safety blocker like RR.
• D: Normal BP supports stability but does not address respiratory status.
5) The nurse enters a room and finds a patient with a fire. What is the best
immediate action?
A. Run to get more oxygen equipment.
B. Activate the facility fire response and remove the patient from the source.
,C. Apply more oxygen to maintain oxygen saturation.
D. Open doors to increase airflow to the room.
Answer: B
• A: Oxygen near fire increases risk; do not run for more oxygen.
• B: Correct—follow fire protocol, remove patient from danger, shut off/contain if possible
per policy.
• C: Oxygen increases fire hazard.
• D: Opening doors can feed oxygen to the fire; follow protocol instead.
6) A nurse is caring for a patient with a new prescription for warfarin. Which
teaching is most accurate?
A. “Warfarin is used for immediate clot relief.”
B. “Avoid green leafy vegetables because they cause bleeding.”
C. “You will need regular INR monitoring.”
D. “You do not need to report bleeding or bruising.”
Answer: C
• A: Warfarin is not immediate; it takes days to become therapeutic.
• B: Green leafy vegetables contain vitamin K; consistent intake is needed—avoid sudden
changes, don’t fully eliminate unless instructed.
• C: Correct—INR monitoring is essential.
• D: Bleeding/bruising must be reported.
7) Which patient requires the nurse to check the glucose first?
A. A patient with diabetes who reports hunger and tremors.
B. A patient with an order for sliding-scale insulin.
C. A patient who is scheduled for a morning fingerstick.
D. A patient with no history of diabetes.
Answer: A
• A: Symptoms suggest hypoglycemia—glucose check immediately.
• B: Still important, but symptoms are acute priority.
• C: Scheduled checks are routine; treat symptoms first if present.
• D: No diabetes history means lower risk, not immediate need.
, 8) A nurse is prioritizing care. Which task should be performed first?
A. Reassess a patient’s pain after medication.
B. Take a blood glucose on a patient with insulin due.
C. Assess a patient with BP 86/50 and decreased LOC.
D. Document intake/output for the shift.
Answer: C
• A: Important, but not as immediately unsafe as unstable vitals.
• B: Routine safety task; but unstable LOC/BP is higher acuity.
• C: Hypotension with decreased LOC may indicate shock—highest priority.
• D: Documentation is not first when a patient is unstable.
9) A patient’s lab work shows creatinine rising. Which nursing action is
appropriate for a medication that is renally cleared?
A. Give the dose as usual with no adjustments.
B. Continue the medication and ignore lab changes.
C. Notify provider/pharmacist to evaluate renal dosing.
D. Stop the medication immediately without orders.
Answer: C
• A: Renal dosing often changes with impaired function.
• B: Lab changes must be acted upon.
• C: Correct—renal adjustment must be ordered/verified.
• D: Nurses generally do not unilaterally stop; coordinate/notify for orders.
10) A nurse is teaching a patient about anticoagulants. Which statement
indicates correct understanding?
A. “I should take aspirin daily to prevent bleeding.”
B. “I should avoid activities that could cause injury.”
C. “I can stop the medication if I feel better.”
D. “I don’t need to report dark urine.”
Answer: B
• A: Aspirin increases bleeding risk unless specifically prescribed; incorrect teaching.
• B: Correct—reduce injury risk (falls, sharp injuries).
• C: Anticoagulants should not be stopped without provider direction.
