Latest 2025/2026 HESI PN Exit Exam Version 2: 160
Genuine Questions & Verified Detailed Answers ---
**1. Which action is priority before giving any medication?**
A. Check allergies
B. Assess vital signs
C. Review diagnosis
D. Ask about pain
**Answer: A. Check allergies**
*Rationale: Checking for allergies is the most critical safety step to
prevent a life-threatening allergic reaction. Other assessments are
important but secondary.*
**2. The nurse enters a room and finds a client unresponsive. What is
the first action?**
A. Call family
B. Check pulse
C. Start CPR
D. Call provider
**Answer: B. Check pulse**
*Rationale: The nurse must first check for a pulse to determine if CPR is
needed. This is part of the initial assessment (CABs).*
,**3. Which client requires immediate attention?**
A. Stable post-op client
B. Client with chest pain
C. Client requesting pain meds
D. Client ready for discharge
**Answer: B. Client with chest pain**
*Rationale: Chest pain may indicate a myocardial infarction and
requires immediate assessment. This is a life-threatening emergency.*
**4. What is the best infection control measure?**
A. Mask use
B. Hand hygiene
C. Sterile gloves
D. Antibiotics
**Answer: B. Hand hygiene**
*Rationale: Hand hygiene is the single most effective way to prevent
the spread of healthcare-associated infections.*
**5. Priority nursing action for a fall risk client?**
A. Bed in high position
B. Bed in low position
C. Raise all side rails
D. Place call light within reach
,**Answer: B. Bed in low position**
*Rationale: Keeping the bed in the lowest position reduces the risk of
injury from falling out of bed. This is a basic safety measure.*
**6. A client with a history of hypertension reports dizziness. Best way
to assess BP?**
A. In supine position only
B. In supine, sitting, and standing positions
C. In sitting position only
D. In standing position only
**Answer: B. In supine, sitting, and standing positions**
*Rationale: This allows assessment for orthostatic hypotension, which
is a drop in BP upon position change causing dizziness.*
**7. A client is receiving a blood transfusion and reports low back pain
and itching. Priority action?**
A. Stop the transfusion
B. Slow the infusion rate
C. Assess vital signs
D. Notify the provider
**Answer: A. Stop the transfusion**
*Rationale: Low back pain and itching indicate a hemolytic transfusion
reaction. The blood must be stopped immediately to prevent kidney
failure.*
, **8. An elderly client is admitted with dehydration. After IV fluids, the
client becomes confused. Priority action?**
A. Apply restraints
B. Reorient the client
C. Assess for electrolyte imbalances
D. Notify the provider immediately
**Answer: C. Assess for electrolyte imbalances**
*Rationale: Confusion in an elderly client after IV fluids often indicates
electrolyte imbalance (like hyponatremia), requiring assessment before
intervention.*
**9. A client is on a cardiac monitor. The alarm sounds but the client is
watching TV. First action?**
A. Call a code blue
B. Press the recorder button
C. Check the client and lead placement
D. Call the healthcare provider
**Answer: C. Check the client and lead placement**
*Rationale: Always assess the client first. The alarm may be due to lead
detachment or movement, not a true dysrhythmia.*
**10. A client with heart failure has extreme dyspnea and crackles.
Expected interventions? (SATA)**
Genuine Questions & Verified Detailed Answers ---
**1. Which action is priority before giving any medication?**
A. Check allergies
B. Assess vital signs
C. Review diagnosis
D. Ask about pain
**Answer: A. Check allergies**
*Rationale: Checking for allergies is the most critical safety step to
prevent a life-threatening allergic reaction. Other assessments are
important but secondary.*
**2. The nurse enters a room and finds a client unresponsive. What is
the first action?**
A. Call family
B. Check pulse
C. Start CPR
D. Call provider
**Answer: B. Check pulse**
*Rationale: The nurse must first check for a pulse to determine if CPR is
needed. This is part of the initial assessment (CABs).*
,**3. Which client requires immediate attention?**
A. Stable post-op client
B. Client with chest pain
C. Client requesting pain meds
D. Client ready for discharge
**Answer: B. Client with chest pain**
*Rationale: Chest pain may indicate a myocardial infarction and
requires immediate assessment. This is a life-threatening emergency.*
**4. What is the best infection control measure?**
A. Mask use
B. Hand hygiene
C. Sterile gloves
D. Antibiotics
**Answer: B. Hand hygiene**
*Rationale: Hand hygiene is the single most effective way to prevent
the spread of healthcare-associated infections.*
**5. Priority nursing action for a fall risk client?**
A. Bed in high position
B. Bed in low position
C. Raise all side rails
D. Place call light within reach
,**Answer: B. Bed in low position**
*Rationale: Keeping the bed in the lowest position reduces the risk of
injury from falling out of bed. This is a basic safety measure.*
**6. A client with a history of hypertension reports dizziness. Best way
to assess BP?**
A. In supine position only
B. In supine, sitting, and standing positions
C. In sitting position only
D. In standing position only
**Answer: B. In supine, sitting, and standing positions**
*Rationale: This allows assessment for orthostatic hypotension, which
is a drop in BP upon position change causing dizziness.*
**7. A client is receiving a blood transfusion and reports low back pain
and itching. Priority action?**
A. Stop the transfusion
B. Slow the infusion rate
C. Assess vital signs
D. Notify the provider
**Answer: A. Stop the transfusion**
*Rationale: Low back pain and itching indicate a hemolytic transfusion
reaction. The blood must be stopped immediately to prevent kidney
failure.*
, **8. An elderly client is admitted with dehydration. After IV fluids, the
client becomes confused. Priority action?**
A. Apply restraints
B. Reorient the client
C. Assess for electrolyte imbalances
D. Notify the provider immediately
**Answer: C. Assess for electrolyte imbalances**
*Rationale: Confusion in an elderly client after IV fluids often indicates
electrolyte imbalance (like hyponatremia), requiring assessment before
intervention.*
**9. A client is on a cardiac monitor. The alarm sounds but the client is
watching TV. First action?**
A. Call a code blue
B. Press the recorder button
C. Check the client and lead placement
D. Call the healthcare provider
**Answer: C. Check the client and lead placement**
*Rationale: Always assess the client first. The alarm may be due to lead
detachment or movement, not a true dysrhythmia.*
**10. A client with heart failure has extreme dyspnea and crackles.
Expected interventions? (SATA)**
