HESI PN Exit Exam Version 2– Full 160
Questions with Detailed Verified Answers
Based on HESI Comprehensive Review for
the NCLEX-PN® Examination, 7th Edition
by HESI
**
1. A client is prescribed digoxin (Lanoxin) and furosemide (Lasix). Which
assessment finding requires the most immediate intervention by the
PN?**
A. Blood pressure of 130/80 mmHg
B. Heart rate of 58 beats per minute
C. Respiratory rate of 22 breaths per minute
D. Urinary output of 60 mL over the past 2 hours
**Answer: B. Heart rate of 58 beats per minute**
**Rationale:** Digoxin toxicity risk increases with hypokalemia (a
common side effect of furosemide, a potassium-wasting diuretic). A
hallmark sign of digoxin toxicity is bradycardia. A heart rate below 60
requires holding the digoxin and notifying the provider.
,**2. The PN is caring for a client receiving a continuous tube feeding.
Which intervention is most important to prevent aspiration?**
A. Flush the tube with 30 mL of water every 4 hours.
B. Check the residual volume every 4 hours.
C. Keep the head of the bed elevated to 30-45 degrees.
D. Change the tubing every 24 hours.
**Answer: C. Keep the head of the bed elevated to 30-45 degrees.**
**Rationale:** Maintaining semi-Fowler's position (30-45 degrees) uses
gravity to prevent gastric contents from refluxing into the esophagus
and being aspirated. This is the priority safety intervention.
**3. A client with a new diagnosis of diabetes mellitus is learning to
self-administer insulin. The client draws up the NPH insulin first, then
the regular insulin. What action should the PN take?**
A. Praise the client for using the correct technique.
B. Remind the client to roll the NPH vial before drawing it up.
C. Instruct the client to discard the mixture and start over.
D. Document that the client requires further teaching.
**Answer: C. Instruct the client to discard the mixture and start over.**
**Rationale:** The principle of "clear to cloudy" must be followed
when mixing insulins. Regular insulin (clear) should be drawn up first to
prevent contamination of the regular vial with NPH (cloudy). Drawing
,up the NPH first contaminates the regular insulin, altering its onset of
action.
**4. A PN is reinforcing teaching for a client with a new colostomy. The
client states, "I don't think I will ever be able to look at this." Which
response by the PN is most therapeutic?**
A. "Don't worry; most people feel that way at first."
B. "You feel this is going to be very difficult for you."
C. "Would you like to talk to someone who has a colostomy?"
D. "Your family will be a great source of support for you."
**Answer: B. "You feel this is going to be very difficult for you."**
**Rationale:** This response uses reflection, a therapeutic
communication technique that acknowledges the client's feeling
without judgment. It encourages the client to express more emotions
and validates their perspective.
**5. A client is 2 days post-operative following a total hip arthroplasty.
Which action should the PN instruct the UAP to report immediately?**
A. The client's oral temperature is 99.0°F (37.2°C).
B. The client's breakfast tray is untouched.
C. The client's operative leg is noticeably shorter than the other leg.
D. The client's urinary output was 200 mL in the last 4 hours.
, **Answer: C. The client's operative leg is noticeably shorter than the
other leg.**
**Rationale:** Leg length discrepancy after a hip replacement is a
classic sign of hip prosthesis dislocation. This is a medical emergency
requiring immediate intervention.
**6. A client is receiving a blood transfusion. Fifteen minutes after the
start of the transfusion, the client reports low back pain and chills.
What is the PN's priority action?**
A. Slow the infusion rate and assess vital signs.
B. Stop the transfusion and infuse normal saline.
C. Notify the charge nurse and blood bank.
D. Place the client in a supine position.
**Answer: B. Stop the transfusion and infuse normal saline.**
**Rationale:** Back pain, chills, and fever are signs of a hemolytic
transfusion reaction. The priority is to stop the transfusion immediately
to prevent further reaction, then maintain IV access with normal saline
and notify the provider.
**7. A client with heart failure is prescribed a low-sodium diet. Which
food choice by the client indicates effective teaching?**
A. A ham sandwich on white bread
B. A baked potato with unsalted butter
C. A can of tomato soup with crackers
Questions with Detailed Verified Answers
Based on HESI Comprehensive Review for
the NCLEX-PN® Examination, 7th Edition
by HESI
**
1. A client is prescribed digoxin (Lanoxin) and furosemide (Lasix). Which
assessment finding requires the most immediate intervention by the
PN?**
A. Blood pressure of 130/80 mmHg
B. Heart rate of 58 beats per minute
C. Respiratory rate of 22 breaths per minute
D. Urinary output of 60 mL over the past 2 hours
**Answer: B. Heart rate of 58 beats per minute**
**Rationale:** Digoxin toxicity risk increases with hypokalemia (a
common side effect of furosemide, a potassium-wasting diuretic). A
hallmark sign of digoxin toxicity is bradycardia. A heart rate below 60
requires holding the digoxin and notifying the provider.
,**2. The PN is caring for a client receiving a continuous tube feeding.
Which intervention is most important to prevent aspiration?**
A. Flush the tube with 30 mL of water every 4 hours.
B. Check the residual volume every 4 hours.
C. Keep the head of the bed elevated to 30-45 degrees.
D. Change the tubing every 24 hours.
**Answer: C. Keep the head of the bed elevated to 30-45 degrees.**
**Rationale:** Maintaining semi-Fowler's position (30-45 degrees) uses
gravity to prevent gastric contents from refluxing into the esophagus
and being aspirated. This is the priority safety intervention.
**3. A client with a new diagnosis of diabetes mellitus is learning to
self-administer insulin. The client draws up the NPH insulin first, then
the regular insulin. What action should the PN take?**
A. Praise the client for using the correct technique.
B. Remind the client to roll the NPH vial before drawing it up.
C. Instruct the client to discard the mixture and start over.
D. Document that the client requires further teaching.
**Answer: C. Instruct the client to discard the mixture and start over.**
**Rationale:** The principle of "clear to cloudy" must be followed
when mixing insulins. Regular insulin (clear) should be drawn up first to
prevent contamination of the regular vial with NPH (cloudy). Drawing
,up the NPH first contaminates the regular insulin, altering its onset of
action.
**4. A PN is reinforcing teaching for a client with a new colostomy. The
client states, "I don't think I will ever be able to look at this." Which
response by the PN is most therapeutic?**
A. "Don't worry; most people feel that way at first."
B. "You feel this is going to be very difficult for you."
C. "Would you like to talk to someone who has a colostomy?"
D. "Your family will be a great source of support for you."
**Answer: B. "You feel this is going to be very difficult for you."**
**Rationale:** This response uses reflection, a therapeutic
communication technique that acknowledges the client's feeling
without judgment. It encourages the client to express more emotions
and validates their perspective.
**5. A client is 2 days post-operative following a total hip arthroplasty.
Which action should the PN instruct the UAP to report immediately?**
A. The client's oral temperature is 99.0°F (37.2°C).
B. The client's breakfast tray is untouched.
C. The client's operative leg is noticeably shorter than the other leg.
D. The client's urinary output was 200 mL in the last 4 hours.
, **Answer: C. The client's operative leg is noticeably shorter than the
other leg.**
**Rationale:** Leg length discrepancy after a hip replacement is a
classic sign of hip prosthesis dislocation. This is a medical emergency
requiring immediate intervention.
**6. A client is receiving a blood transfusion. Fifteen minutes after the
start of the transfusion, the client reports low back pain and chills.
What is the PN's priority action?**
A. Slow the infusion rate and assess vital signs.
B. Stop the transfusion and infuse normal saline.
C. Notify the charge nurse and blood bank.
D. Place the client in a supine position.
**Answer: B. Stop the transfusion and infuse normal saline.**
**Rationale:** Back pain, chills, and fever are signs of a hemolytic
transfusion reaction. The priority is to stop the transfusion immediately
to prevent further reaction, then maintain IV access with normal saline
and notify the provider.
**7. A client with heart failure is prescribed a low-sodium diet. Which
food choice by the client indicates effective teaching?**
A. A ham sandwich on white bread
B. A baked potato with unsalted butter
C. A can of tomato soup with crackers
