2025 RN HESI EXIT EXAM Version 1
(V1)and (v2) – All 160 Questions &
Answers!! (Actual Screenshots from exam
2023 A+) (All Included!!)
1. A nurse is assessing a client with heart failure who reports
sudden dyspnea, coughing, and pink, frothy sputum. Which action
should the nurse take first?
A. Administer oxygen via nasal cannula at 2 L/min
B. Place the client in high-Fowler’s position
C. Notify the healthcare provider
D. Check O₂ saturation with a pulse oximeter
Answer: B
Rationale: This client is exhibiting signs of acute pulmonary
edema. High-Fowler’s position reduces venous return (preload)
and uses gravity to improve lung expansion, which is the
immediate priority. Oxygen (A) is critical but positioning comes
first because it can be done instantly while calling for help.
Notifying the HCP (C) and checking SpO₂ (D) are important but
delayed actions after positioning and oxygen.
2. A client with type 1 diabetes mellitus has a blood glucose level
of 52 mg/dL and is conscious but confused. What should the
nurse administer first?
, A. 4 oz of orange juice
B. Glucagon 1 mg IM
C. 50% dextrose IV push
D. 8 oz of skim milk
Answer: A
Rationale: The client is conscious and able to swallow, so the
“rule of 15” applies: give 15 g of fast-acting carbohydrate (4 oz
juice or regular soda). IV dextrose (C) is for unconscious clients.
Glucagon (B) is for severe hypoglycemia without IV access. Skim
milk (D) contains protein which slows glucose absorption.
3. A nurse is caring for a postoperative client who suddenly
develops chest pain, tachypnea, and oxygen saturation of 88% on
room air. Which complication is most likely?
A. Atelectasis
B. Pulmonary embolism
C. Pneumothorax
D. Wound infection
Answer: B
Rationale: Sudden onset of pleuritic chest pain, tachypnea, and
hypoxemia in a postoperative client is classic for pulmonary
embolism (thrombus from deep veins). Atelectasis (A) develops
more gradually. Pneumothorax (C) would have absent breath
sounds on one side. Wound infection (D) does not cause acute
hypoxia.
,4. The nurse is delegating tasks to an unlicensed assistive
personnel (UAP). Which task is appropriate for the UAP?
A. Reinforcing a sterile dressing change for a pressure injury
B. Interpreting a client’s telemetry rhythm strip
C. Feeding a client with dysphagia who has a safe swallow
screen
D. Assessing a client’s lung sounds after a bronchodilator
treatment
Answer: C
Rationale: UAPs can perform feeding if the client has passed a
swallow screen and no choking risk. Reinforcing sterile dressings
(A) is not allowed in most states; interpretation (B) and
assessment (D) require licensed nursing judgment.
5. A client taking lithium carbonate reports nausea, blurred vision,
and hand tremors. The nurse notes a lithium level of 1.8 mEq/L.
What is the priority action?
A. Administer haloperidol as needed for tremors
B. Hold the next dose and notify the healthcare provider
C. Increase fluids to 3 L/day
D. Reassure the client these are expected side effects
Answer: B
Rationale: Therapeutic lithium range is 0.6–1.2 mEq/L. 1.8 mEq/L
, is toxic. The nurse should hold the next dose, notify the provider,
and prepare for possible hemodialysis if severe. Administering
haloperidol (A) increases neurotoxicity. Increasing fluids (C) helps
chronic mild toxicity but not acute toxicity. Reassurance (D) is
dangerous.
6. A nurse is caring for a client receiving a blood transfusion of
packed red blood cells. 15 minutes after the start, the client
reports chills and low back pain. Which action should the nurse
take first?
A. Stop the transfusion
B. Slow the infusion rate
C. Administer acetaminophen as ordered
D. Flush the IV line with normal saline
Answer: A
Rationale: Chills and back pain suggest an acute hemolytic
reaction (ABO incompatibility). The first action is to stop the
transfusion immediately to prevent further hemolysis. Then
disconnect tubing, keep IV line open with saline, notify the
provider. Slowing (B) is wrong; the reaction will continue.
Acetaminophen (C) can be given later but not first.
(V1)and (v2) – All 160 Questions &
Answers!! (Actual Screenshots from exam
2023 A+) (All Included!!)
1. A nurse is assessing a client with heart failure who reports
sudden dyspnea, coughing, and pink, frothy sputum. Which action
should the nurse take first?
A. Administer oxygen via nasal cannula at 2 L/min
B. Place the client in high-Fowler’s position
C. Notify the healthcare provider
D. Check O₂ saturation with a pulse oximeter
Answer: B
Rationale: This client is exhibiting signs of acute pulmonary
edema. High-Fowler’s position reduces venous return (preload)
and uses gravity to improve lung expansion, which is the
immediate priority. Oxygen (A) is critical but positioning comes
first because it can be done instantly while calling for help.
Notifying the HCP (C) and checking SpO₂ (D) are important but
delayed actions after positioning and oxygen.
2. A client with type 1 diabetes mellitus has a blood glucose level
of 52 mg/dL and is conscious but confused. What should the
nurse administer first?
, A. 4 oz of orange juice
B. Glucagon 1 mg IM
C. 50% dextrose IV push
D. 8 oz of skim milk
Answer: A
Rationale: The client is conscious and able to swallow, so the
“rule of 15” applies: give 15 g of fast-acting carbohydrate (4 oz
juice or regular soda). IV dextrose (C) is for unconscious clients.
Glucagon (B) is for severe hypoglycemia without IV access. Skim
milk (D) contains protein which slows glucose absorption.
3. A nurse is caring for a postoperative client who suddenly
develops chest pain, tachypnea, and oxygen saturation of 88% on
room air. Which complication is most likely?
A. Atelectasis
B. Pulmonary embolism
C. Pneumothorax
D. Wound infection
Answer: B
Rationale: Sudden onset of pleuritic chest pain, tachypnea, and
hypoxemia in a postoperative client is classic for pulmonary
embolism (thrombus from deep veins). Atelectasis (A) develops
more gradually. Pneumothorax (C) would have absent breath
sounds on one side. Wound infection (D) does not cause acute
hypoxia.
,4. The nurse is delegating tasks to an unlicensed assistive
personnel (UAP). Which task is appropriate for the UAP?
A. Reinforcing a sterile dressing change for a pressure injury
B. Interpreting a client’s telemetry rhythm strip
C. Feeding a client with dysphagia who has a safe swallow
screen
D. Assessing a client’s lung sounds after a bronchodilator
treatment
Answer: C
Rationale: UAPs can perform feeding if the client has passed a
swallow screen and no choking risk. Reinforcing sterile dressings
(A) is not allowed in most states; interpretation (B) and
assessment (D) require licensed nursing judgment.
5. A client taking lithium carbonate reports nausea, blurred vision,
and hand tremors. The nurse notes a lithium level of 1.8 mEq/L.
What is the priority action?
A. Administer haloperidol as needed for tremors
B. Hold the next dose and notify the healthcare provider
C. Increase fluids to 3 L/day
D. Reassure the client these are expected side effects
Answer: B
Rationale: Therapeutic lithium range is 0.6–1.2 mEq/L. 1.8 mEq/L
, is toxic. The nurse should hold the next dose, notify the provider,
and prepare for possible hemodialysis if severe. Administering
haloperidol (A) increases neurotoxicity. Increasing fluids (C) helps
chronic mild toxicity but not acute toxicity. Reassurance (D) is
dangerous.
6. A nurse is caring for a client receiving a blood transfusion of
packed red blood cells. 15 minutes after the start, the client
reports chills and low back pain. Which action should the nurse
take first?
A. Stop the transfusion
B. Slow the infusion rate
C. Administer acetaminophen as ordered
D. Flush the IV line with normal saline
Answer: A
Rationale: Chills and back pain suggest an acute hemolytic
reaction (ABO incompatibility). The first action is to stop the
transfusion immediately to prevent further hemolysis. Then
disconnect tubing, keep IV line open with saline, notify the
provider. Slowing (B) is wrong; the reaction will continue.
Acetaminophen (C) can be given later but not first.
