HESI RN EXIT EXAM – 140 Questions
and Verified Answers Detailed Rationales
| 2024 Edition
Question 1
The emergency room nurse admits a child who experienced a seizure at school.
This is the first occurrence, and the mother denies any family history of epilepsy.
Which response by the nurse is best?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long-term treatment will prevent future seizures."
Answer: B
Rationale: A single seizure does not automatically diagnose epilepsy (recurrent
unprovoked seizures). The nurse should provide accurate, non-alarming
information. Option B is truthful and avoids false reassurance. Option A dismisses
the mother's concern. Option C is uncertain. Option D assumes need for long-term
treatment prematurely.
Question 2
The father of an 8-month-old infant asks the nurse if his infant's vocalization is
normal for his age. Which vocalization would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
Answer: B
Rationale: By 6-9 months, infants begin to imitate sounds (e.g., "mama," "dada"
without meaning). Cooing occurs at 2-3 months. Throaty sounds are typical in
early infancy. Laughter appears around 4-5 months.
,Question 3
The health care provider orders “aspirate nasogastric (NG) tube for residual.” The
pH of the aspirate is 10. Which action should the nurse take?
A) Administer 10 mL of 0.9% sodium chloride.
B) Administer 10 mL of 0.9% sodium bicarbonate.
C) Administer 10 mL of 0.9% sodium citrate.
D) Administer 10 mL of 0.9% sodium phosphate.
Answer: B
Rationale: actual nursing action is to obtain x-ray.
Question 4
The nurse explains lab results to a mother whose child has iron deficiency anemia.
Which statement by the nurse is most accurate?
A) "Although the results are here, your doctor will explain them later."
B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."
Answer: B
*Rationale: Iron deficiency anemia results in microcytic, hypochromic RBCs with
reduced oxygen-carrying capacity. Option B is clear and accurate
Question 5
The nurse admits a client newly diagnosed with hypertension. What is the correct
method for assessing blood pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position
,Answer: B
*Rationale: Initial BP should be taken in both arms; a significant difference (>10
mmHg) may indicate subclavian stenosis or aortic dissection. Subsequent readings
use the arm with the higher pressure. Standing/sitting are for orthostatic checks,
not initial diagnosis.*
Question 6
The nurse asks a client with a history of alcoholism about his drinking. He says, "I
didn't hurt anyone, I just like to have a good time, and drinking helps me relax."
Which defense mechanism is the client using?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization
Answer: D
Rationale: Rationalization – justifying unacceptable behavior with
logical-sounding reasons ("I just like to have a good time," "it helps me relax").
Denial would be denying any problem. Projection attributes feelings to others.
Intellectualization uses excessive reasoning to avoid emotions.
Question 7
The nurse assesses delayed gross motor development in a 5-year-old child. Which
finding would support this?
A) Unable to hop on one foot
B) Unable to draw a circle
C) Unable to use scissors
D) Unable to name four colors
Answer: A
*Rationale: By age 5, a child should be able to hop on one foot, skip, and walk
backward. Drawing a circle, using scissors, and naming colors are fine
motor/cognitive skills, not gross motor.*
, Question 8
A client with heart failure is receiving furosemide (Lasix) IV. Which assessment
finding requires immediate nursing intervention?
A) Serum potassium 3.1 mEq/L
B) Urine output 150 mL in 2 hours
C) Blood pressure 110/70 mmHg
D) Weight loss of 1 kg in 24 hours
Answer: A
*Rationale: Furosemide causes hypokalemia (K <3.5). Severe hypokalemia
increases risk of cardiac arrhythmias. Urine output 150 mL/2h is adequate (75
mL/h). BP 110/70 is acceptable. Weight loss of 1 kg in 24 hours is expected
diuresis.*
Question 9
A postpartum nurse teaches a new mother about signs of infection. Which
statement indicates understanding?
A) "I should call the doctor if my temperature is 100.4°F or higher."
B) "Redness around my C-section incision is normal for a week."
C) "Foul-smelling lochia is expected during the first 3 days."
D) "I will notify my provider if I have pain or burning when I urinate."
Answer: D
*Rationale: Pain/burning on urination may indicate a UTI, common postpartum.
Temperature >100.4°F (38°C) after the first 24 hours is abnormal. Redness around
incision suggests infection. Foul lochia indicates endometritis.*
Question 10
A client with bipolar disorder, manic phase, is pacing and talking rapidly. Which
nursing intervention is most appropriate?
A) Provide a quiet, low-stimulation environment
B) Engage the client in a competitive game
and Verified Answers Detailed Rationales
| 2024 Edition
Question 1
The emergency room nurse admits a child who experienced a seizure at school.
This is the first occurrence, and the mother denies any family history of epilepsy.
Which response by the nurse is best?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long-term treatment will prevent future seizures."
Answer: B
Rationale: A single seizure does not automatically diagnose epilepsy (recurrent
unprovoked seizures). The nurse should provide accurate, non-alarming
information. Option B is truthful and avoids false reassurance. Option A dismisses
the mother's concern. Option C is uncertain. Option D assumes need for long-term
treatment prematurely.
Question 2
The father of an 8-month-old infant asks the nurse if his infant's vocalization is
normal for his age. Which vocalization would the nurse expect at this age?
A) Cooing
B) Imitation of sounds
C) Throaty sounds
D) Laughter
Answer: B
Rationale: By 6-9 months, infants begin to imitate sounds (e.g., "mama," "dada"
without meaning). Cooing occurs at 2-3 months. Throaty sounds are typical in
early infancy. Laughter appears around 4-5 months.
,Question 3
The health care provider orders “aspirate nasogastric (NG) tube for residual.” The
pH of the aspirate is 10. Which action should the nurse take?
A) Administer 10 mL of 0.9% sodium chloride.
B) Administer 10 mL of 0.9% sodium bicarbonate.
C) Administer 10 mL of 0.9% sodium citrate.
D) Administer 10 mL of 0.9% sodium phosphate.
Answer: B
Rationale: actual nursing action is to obtain x-ray.
Question 4
The nurse explains lab results to a mother whose child has iron deficiency anemia.
Which statement by the nurse is most accurate?
A) "Although the results are here, your doctor will explain them later."
B) "Your child has fewer red blood cells that carry oxygen."
C) "The blood cells that carry nutrients to the cells are too large."
D) "There are not enough blood cells in your child's circulation."
Answer: B
*Rationale: Iron deficiency anemia results in microcytic, hypochromic RBCs with
reduced oxygen-carrying capacity. Option B is clear and accurate
Question 5
The nurse admits a client newly diagnosed with hypertension. What is the correct
method for assessing blood pressure?
A) Standing and sitting
B) In both arms
C) After exercising
D) Supine position
,Answer: B
*Rationale: Initial BP should be taken in both arms; a significant difference (>10
mmHg) may indicate subclavian stenosis or aortic dissection. Subsequent readings
use the arm with the higher pressure. Standing/sitting are for orthostatic checks,
not initial diagnosis.*
Question 6
The nurse asks a client with a history of alcoholism about his drinking. He says, "I
didn't hurt anyone, I just like to have a good time, and drinking helps me relax."
Which defense mechanism is the client using?
A) Denial
B) Projection
C) Intellectualization
D) Rationalization
Answer: D
Rationale: Rationalization – justifying unacceptable behavior with
logical-sounding reasons ("I just like to have a good time," "it helps me relax").
Denial would be denying any problem. Projection attributes feelings to others.
Intellectualization uses excessive reasoning to avoid emotions.
Question 7
The nurse assesses delayed gross motor development in a 5-year-old child. Which
finding would support this?
A) Unable to hop on one foot
B) Unable to draw a circle
C) Unable to use scissors
D) Unable to name four colors
Answer: A
*Rationale: By age 5, a child should be able to hop on one foot, skip, and walk
backward. Drawing a circle, using scissors, and naming colors are fine
motor/cognitive skills, not gross motor.*
, Question 8
A client with heart failure is receiving furosemide (Lasix) IV. Which assessment
finding requires immediate nursing intervention?
A) Serum potassium 3.1 mEq/L
B) Urine output 150 mL in 2 hours
C) Blood pressure 110/70 mmHg
D) Weight loss of 1 kg in 24 hours
Answer: A
*Rationale: Furosemide causes hypokalemia (K <3.5). Severe hypokalemia
increases risk of cardiac arrhythmias. Urine output 150 mL/2h is adequate (75
mL/h). BP 110/70 is acceptable. Weight loss of 1 kg in 24 hours is expected
diuresis.*
Question 9
A postpartum nurse teaches a new mother about signs of infection. Which
statement indicates understanding?
A) "I should call the doctor if my temperature is 100.4°F or higher."
B) "Redness around my C-section incision is normal for a week."
C) "Foul-smelling lochia is expected during the first 3 days."
D) "I will notify my provider if I have pain or burning when I urinate."
Answer: D
*Rationale: Pain/burning on urination may indicate a UTI, common postpartum.
Temperature >100.4°F (38°C) after the first 24 hours is abnormal. Redness around
incision suggests infection. Foul lochia indicates endometritis.*
Question 10
A client with bipolar disorder, manic phase, is pacing and talking rapidly. Which
nursing intervention is most appropriate?
A) Provide a quiet, low-stimulation environment
B) Engage the client in a competitive game
