HESI RN EXIT EXAM LEGACY V2 Comprehensive
Questions with Correct Answers & Detailed
Rationales 100% Complete – 100 Verified Questions
Latest Update | Instant Download PDF
Q1. A 64-year-old client scheduled for surgery with a general anesthetic has a set
of dentures. Before leaving the unit for the operating room, what is the most
appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out because they are a risk in
the operating room
B) Ask the client if there are second thoughts about having surgery
C) Notify the anesthesia department and the surgeon of the client's dentures
D) Ask the client if the preference would be to remove the dentures in the
operating room receiving area
Correct Answer: D
Rationale: Dentures should be removed before general anesthesia to prevent
aspiration or airway obstruction. However, many clients prefer to keep them until
the last moment for comfort and dignity. Asking the client about preference for
removal in the receiving area respects autonomy while ensuring safety.
Q2. The nurse has been teaching adult clients about cardiac risk assessment.
Which form of evaluation would best measure effectiveness of the teaching?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes
Correct Answer: D
Rationale: The ultimate goal of client teaching is behavior change that reduces
risk. Written tests and verbal questions measure knowledge, not application.
Reported behavioral changes (e.g., diet, exercise, smoking cessation) are the most
meaningful outcome measure.
,Q3. A client with a history of marital conflict repeatedly complains of severe
headaches that have no organic basis. The nurse recognizes that this conversion of
a mental conflict to a physical symptom serves which primary purpose?
A) Such fantasies can gratify unconscious wishes
B) The physical symptom allows the client to avoid a painful situation
C) This conversion reduces anxiety by transforming it into a physical complaint
D) Isolating the feelings reduces conflict within the relationship
Correct Answer: C
Rationale: Conversion disorder involves the transformation of psychological
stress into physical symptoms (e.g., headaches, weakness). The primary purpose is
to reduce anxiety by externalizing the conflict into a bodily complaint that is more
acceptable or less threatening than the underlying emotional issue.
Q4. A client with type 1 diabetes mellitus is found unconscious. Which action
should the nurse take first?
A) Administer glucagon subcutaneously
B) Check the blood glucose level
C) Start an IV infusion of normal saline
D) Give orange juice orally
Correct Answer: B
Rationale: The priority is to determine the cause of unconsciousness –
hypoglycemia vs. hyperglycemia. Checking blood glucose provides immediate
data. Glucagon is given only if hypoglycemia is confirmed. Oral fluids are unsafe
in an unconscious client due to aspiration risk.
Q5. A client is receiving a continuous heparin infusion for deep vein thrombosis.
The aPTT level is 110 seconds (control 30 seconds). What should the nurse do
first?
A) Increase the heparin infusion rate
B) Continue monitoring as ordered
C) Stop the heparin infusion
D) Administer protamine sulfate IV
Correct Answer: C
Rationale: The therapeutic aPTT for heparin is 1.5-2.5 times control (45-75
seconds). 110 seconds indicates excessive anticoagulation and bleeding risk. The
,nurse should stop the infusion immediately and notify the provider. Protamine is
given for active bleeding or extreme elevations.
Q6. A postpartum client who is Rh-negative gives birth to an Rh-positive infant.
The nurse should administer Rh immunoglobulin (RhoGAM) within what time
frame?
A) 24 hours
B) 48 hours
C) 72 hours
D) 1 week
Correct Answer: C
Rationale: Rh immunoglobulin should be administered within 72 hours of
delivery to prevent maternal sensitization to Rh-positive fetal blood cells. It may be
effective up to 28 days, but 72 hours is the standard recommendation for optimal
protection.
Q7. A client with chronic obstructive pulmonary disease (COPD) has an SpO₂ of
88% on room air. The nurse notes the client is alert and talking. What is the
priority action?
A) Apply oxygen at 2 L/min via nasal cannula
B) Increase oxygen to 4 L/min immediately
C) Assess the client's baseline oxygen saturation
D) Notify the respiratory therapist
Correct Answer: A
Rationale: COPD clients with chronic hypoxia often have a baseline SpO₂ of 88-
92%. The goal is to maintain SpO₂ at 88-92% to avoid CO₂ retention. Applying
low-flow oxygen (2 L/min) is appropriate. High oxygen can reduce hypoxic drive.
Assessment of baseline is helpful but intervention is needed.
Q8. A client with major depressive disorder begins taking phenelzine (Nardil), a
monoamine oxidase inhibitor (MAOI). Which food should the nurse instruct the
client to avoid?
A) Broiled chicken
B) Aged cheese and red wine
C) Fresh fruits
D) White bread
, Correct Answer: B
Rationale: MAOIs block the breakdown of tyramine. Tyramine-rich foods (aged
cheese, cured meats, red wine, fermented foods) can cause hypertensive crisis.
Fresh chicken, fruits, and bread are safe.
Q9. A nurse is caring for a client receiving a blood transfusion. Fifteen minutes
after the start, the client reports chills and low back pain. What is the priority
action?
A) Slow the infusion rate
B) Stop the transfusion
C) Administer acetaminophen
D) Notify the provider
Correct Answer: B
Rationale: Chills and back pain are signs of an acute hemolytic transfusion
reaction. The nurse must stop the transfusion immediately, keep the IV line open
with normal saline, and notify the provider. Slowing the infusion does not prevent
further reaction.
Q10. A client with heart failure has a prescription for furosemide (Lasix) 40 mg IV
push. Which laboratory value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes significant potassium wasting.
Hypokalemia can lead to cardiac dysrhythmias, especially in clients taking
digoxin. Sodium, calcium, and magnesium may also be affected but potassium is
the highest priority.
Q11. A client with a new colostomy asks the nurse, "When should I empty my
pouch?" What is the best response?
A) "Empty it every 8 hours regardless of content"
B) "Empty it when it is one-third to one-half full"
C) "Empty it only when it is completely full"
D) "Empty it after every meal"
Questions with Correct Answers & Detailed
Rationales 100% Complete – 100 Verified Questions
Latest Update | Instant Download PDF
Q1. A 64-year-old client scheduled for surgery with a general anesthetic has a set
of dentures. Before leaving the unit for the operating room, what is the most
appropriate intervention by the nurse?
A) Explain to the client that the dentures must come out because they are a risk in
the operating room
B) Ask the client if there are second thoughts about having surgery
C) Notify the anesthesia department and the surgeon of the client's dentures
D) Ask the client if the preference would be to remove the dentures in the
operating room receiving area
Correct Answer: D
Rationale: Dentures should be removed before general anesthesia to prevent
aspiration or airway obstruction. However, many clients prefer to keep them until
the last moment for comfort and dignity. Asking the client about preference for
removal in the receiving area respects autonomy while ensuring safety.
Q2. The nurse has been teaching adult clients about cardiac risk assessment.
Which form of evaluation would best measure effectiveness of the teaching?
A) Performance on written tests
B) Responses to verbal questions
C) Completion of a mailed survey
D) Reported behavioral changes
Correct Answer: D
Rationale: The ultimate goal of client teaching is behavior change that reduces
risk. Written tests and verbal questions measure knowledge, not application.
Reported behavioral changes (e.g., diet, exercise, smoking cessation) are the most
meaningful outcome measure.
,Q3. A client with a history of marital conflict repeatedly complains of severe
headaches that have no organic basis. The nurse recognizes that this conversion of
a mental conflict to a physical symptom serves which primary purpose?
A) Such fantasies can gratify unconscious wishes
B) The physical symptom allows the client to avoid a painful situation
C) This conversion reduces anxiety by transforming it into a physical complaint
D) Isolating the feelings reduces conflict within the relationship
Correct Answer: C
Rationale: Conversion disorder involves the transformation of psychological
stress into physical symptoms (e.g., headaches, weakness). The primary purpose is
to reduce anxiety by externalizing the conflict into a bodily complaint that is more
acceptable or less threatening than the underlying emotional issue.
Q4. A client with type 1 diabetes mellitus is found unconscious. Which action
should the nurse take first?
A) Administer glucagon subcutaneously
B) Check the blood glucose level
C) Start an IV infusion of normal saline
D) Give orange juice orally
Correct Answer: B
Rationale: The priority is to determine the cause of unconsciousness –
hypoglycemia vs. hyperglycemia. Checking blood glucose provides immediate
data. Glucagon is given only if hypoglycemia is confirmed. Oral fluids are unsafe
in an unconscious client due to aspiration risk.
Q5. A client is receiving a continuous heparin infusion for deep vein thrombosis.
The aPTT level is 110 seconds (control 30 seconds). What should the nurse do
first?
A) Increase the heparin infusion rate
B) Continue monitoring as ordered
C) Stop the heparin infusion
D) Administer protamine sulfate IV
Correct Answer: C
Rationale: The therapeutic aPTT for heparin is 1.5-2.5 times control (45-75
seconds). 110 seconds indicates excessive anticoagulation and bleeding risk. The
,nurse should stop the infusion immediately and notify the provider. Protamine is
given for active bleeding or extreme elevations.
Q6. A postpartum client who is Rh-negative gives birth to an Rh-positive infant.
The nurse should administer Rh immunoglobulin (RhoGAM) within what time
frame?
A) 24 hours
B) 48 hours
C) 72 hours
D) 1 week
Correct Answer: C
Rationale: Rh immunoglobulin should be administered within 72 hours of
delivery to prevent maternal sensitization to Rh-positive fetal blood cells. It may be
effective up to 28 days, but 72 hours is the standard recommendation for optimal
protection.
Q7. A client with chronic obstructive pulmonary disease (COPD) has an SpO₂ of
88% on room air. The nurse notes the client is alert and talking. What is the
priority action?
A) Apply oxygen at 2 L/min via nasal cannula
B) Increase oxygen to 4 L/min immediately
C) Assess the client's baseline oxygen saturation
D) Notify the respiratory therapist
Correct Answer: A
Rationale: COPD clients with chronic hypoxia often have a baseline SpO₂ of 88-
92%. The goal is to maintain SpO₂ at 88-92% to avoid CO₂ retention. Applying
low-flow oxygen (2 L/min) is appropriate. High oxygen can reduce hypoxic drive.
Assessment of baseline is helpful but intervention is needed.
Q8. A client with major depressive disorder begins taking phenelzine (Nardil), a
monoamine oxidase inhibitor (MAOI). Which food should the nurse instruct the
client to avoid?
A) Broiled chicken
B) Aged cheese and red wine
C) Fresh fruits
D) White bread
, Correct Answer: B
Rationale: MAOIs block the breakdown of tyramine. Tyramine-rich foods (aged
cheese, cured meats, red wine, fermented foods) can cause hypertensive crisis.
Fresh chicken, fruits, and bread are safe.
Q9. A nurse is caring for a client receiving a blood transfusion. Fifteen minutes
after the start, the client reports chills and low back pain. What is the priority
action?
A) Slow the infusion rate
B) Stop the transfusion
C) Administer acetaminophen
D) Notify the provider
Correct Answer: B
Rationale: Chills and back pain are signs of an acute hemolytic transfusion
reaction. The nurse must stop the transfusion immediately, keep the IV line open
with normal saline, and notify the provider. Slowing the infusion does not prevent
further reaction.
Q10. A client with heart failure has a prescription for furosemide (Lasix) 40 mg IV
push. Which laboratory value should the nurse monitor most closely?
A) Serum sodium
B) Serum potassium
C) Serum calcium
D) Serum magnesium
Correct Answer: B
Rationale: Furosemide is a loop diuretic that causes significant potassium wasting.
Hypokalemia can lead to cardiac dysrhythmias, especially in clients taking
digoxin. Sodium, calcium, and magnesium may also be affected but potassium is
the highest priority.
Q11. A client with a new colostomy asks the nurse, "When should I empty my
pouch?" What is the best response?
A) "Empty it every 8 hours regardless of content"
B) "Empty it when it is one-third to one-half full"
C) "Empty it only when it is completely full"
D) "Empty it after every meal"
