HESI COMPREHENSIVE EXIT EXAM
Edition
150 Verified Questions & Answers with Rationales
Aligned with the 2026/2027 Elsevier HESI Curriculum,
Next Generation NCLEX (NGN) Standards, and Current Evidence-Based Clinical Guidelines
Official Question Count: 150 | Status: Verified | Format: Actual Exam
,Key Features
✓ Comprehensive NCLEX-style content across all major nursing disciplines.
✓ Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (CJMM) application in item
scenarios.
✓ Advanced medical-surgical, maternal-newborn, pediatric, and psychiatric nursing integration.
✓ Evidence-based standards for patient safety, infection control, and quality improvement.
✓ Leadership, management, and community health nursing principles applied across care settings.
Updates for 2026
Full integration of the NCSBN Clinical Judgment Measurement Model (CJMM) across all HESI exit scenarios,
emphasizing layered thinking: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take
Action, and Evaluate Outcomes.
Updated 2026 National Patient Safety Goals (NPSGs) for high-alert medications, fall prevention, and preventing
health care-associated infections, with revised hand-off communication standards.
Revised Elsevier clinical reasoning frameworks for managing complex, multi-system patient scenarios,
incorporating the latest sepsis, stroke, and acute coronary syndrome clinical standards.
Abstract
This document presents a comprehensive 150-question actual exam modeled on the 2026/2027 Elsevier HESI
Comprehensive Exit Exam blueprint. It integrates foundational nursing skills with advanced medical-surgical
concepts, maternal-newborn and pediatric care, mental health and psychosocial management, pharmacology
and safe medication administration, and leadership and community health principles. Each item is constructed
using the Next Generation NCLEX Clinical Judgment Measurement Model, requiring the test-taker to recognize
and analyze clinical cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. The
questions reflect the critical clinical judgment required for NCLEX success and program completion, and are
accompanied by rationales, distractor analysis, and references drawn from the 2026 Elsevier HESI curriculum
and current evidence-based clinical standards. This resource is designed to evaluate readiness across the breadth
of nursing knowledge expected of a graduate-level registered nurse entering contemporary practice.
Keywords
HESI Exit Exam, Comprehensive Predictor, RN Nursing, NGN, Clinical Judgment, Medical-Surgical,
Pharmacology, Maternal-Newborn, Patient Safety, NCLEX Readiness
Content Area Overview
Content Area Questions Key Topics Weight
Medical-Surgical Nursing 45 Cardiovascular, respiratory, renal, GI, endocrine, 30%
neurologic, hematologic, musculoskeletal
Maternal-Newborn & Pediatric 30 Antepartum, intrapartum, postpartum, newborn, 20%
Nursing pediatric acute and chronic conditions
Mental Health & Psychosocial 25 Anxiety, mood, psychotic, personality, eating, 17%
Care substance use, trauma-related disorders
Pharmacology & Safe 30 Drug classifications, side effects, interactions, IV 20%
Administration therapy, high-alert medications
Leadership, Community 20 Delegation, prioritization, QI, public health, NGN 13%
Health & NGN Case Studies multi-system clinical judgment scenarios
, TOTAL 150 Comprehensive RN readiness across all 100%
domains
Examination Questions
Domain: Medical-Surgical Nursing
1. A 68-year-old client with heart failure is receiving furosemide 40 mg IV. Which finding best
indicates the medication is having the desired therapeutic effect?
A. Serum potassium increases from 3.2 to 4.0 mEq/L.
B. Urine output increases to 80 mL/hr and dyspnea decreases.
C. Blood pressure rises from 96/60 to 130/84 mmHg.
D. Heart rate decreases from 110 to 64 beats/min.
Correct Answer: B. Urine output increases to 80 mL/hr and dyspnea decreases.
Rationale: Furosemide is a loop diuretic whose primary therapeutic goal in heart failure is reduction of
preload through fluid removal, which is demonstrated by increased urine output and relief of pulmonary
congestion (decreased dyspnea).
Why Wrong: A reflects potassium replacement, not furosemide action (it actually lowers potassium). C reflects
a vasopressor effect, not a diuretic effect. D reflects rate control (e.g., digoxin or beta-blocker), not diuresis.
Reference: Elsevier HESI Comprehensive Review for the NCLEX-RN Examination, 8th ed. (2026), Ch. 30:
Cardiovascular Disorders.
2. A client admitted with acute coronary syndrome reports chest pain rated 8/10. Oxygen is
applied at 2 L/min. Which medication should the nurse administer first?
A. Aspirin 325 mg chewable orally.
B. Nitroglycerin 0.4 mg sublingual.
C. Morphine 4 mg IV push.
D. Atorvastatin 80 mg orally.
Correct Answer: B. Nitroglycerin 0.4 mg sublingual.
Rationale: Sublingual nitroglycerin is the first-line agent for active ischemic chest pain because it acts within
1 to 3 minutes to dilate coronary arteries and reduce myocardial oxygen demand.
Why Wrong: Aspirin should be given promptly but after immediate pain relief is initiated. Morphine is
reserved for pain unresponsive to nitroglycerin. Atorvastatin is long-term therapy, not acute pain relief.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 30: Cardiovascular Disorders; ACC/AHA
2025 ACS Guideline.
3. A client with chronic obstructive pulmonary disease (COPD) has an arterial blood gas (ABG)
result of pH 7.32, PaCO2 58 mmHg, PaO2 62 mmHg, HCO3 30 mEq/L. Which interpretation is
correct?
A. Respiratory alkalosis with metabolic compensation.
B. Uncompensated metabolic acidosis.
C. Partially compensated respiratory acidosis.
D. Fully compensated metabolic alkalosis.
Correct Answer: C. Partially compensated respiratory acidosis.
Rationale: Low pH (acidosis), elevated PaCO2 (respiratory cause), and elevated HCO3 (kidneys retaining
bicarbonate to compensate) indicate partially compensated respiratory acidosis, a classic finding in COPD
exacerbation.
Why Wrong: A is incorrect because PaCO2 is elevated, not low. B is incorrect because the primary cause is
respiratory, not metabolic. D is incorrect because pH is still below normal, so compensation is not complete.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 27: Respiratory Disorders.
4. A nurse is caring for a client with a chest tube connected to a water-seal chamber. The nurse
observes constant bubbling in the water-seal chamber. Which action should the nurse take?
, A. Document the finding as expected.
B. Check the system for an air leak.
C. Clamp the chest tube immediately.
D. Add more water to the suction control chamber.
Correct Answer: B. Check the system for an air leak.
Rationale: Constant bubbling in the water-seal chamber indicates an air leak in the system (or from the
patient), which must be located and addressed. Intermittent bubbling with exhalation is normal, but
continuous bubbling is not.
Why Wrong: A is incorrect because continuous bubbling is abnormal. C clamping can cause tension
pneumothorax and is contraindicated. D addresses the suction control chamber, not the water-seal chamber
leak.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 27: Respiratory Disorders; AARC 2025
Chest Tube Guidelines.
5. A client with type 1 diabetes presents with blood glucose 612 mg/dL, deep rapid respirations,
and a fruity breath odor. Which IV fluid and insulin protocol should the nurse anticipate?
A. 0.45% NaCl with regular insulin infusion at 0.1 units/kg/hr.
B. D5W with NPH insulin 10 units IV push.
C. 0.9% NaCl with regular insulin infusion at 0.1 units/kg/hr.
D. Lactated Ringer's with glargine insulin 20 units subcutaneously.
Correct Answer: C. 0.9% NaCl with regular insulin infusion at 0.1 units/kg/hr.
Rationale: Diabetic ketoacidosis (DKA) is treated with 0.9% NaCl for rapid volume restoration and a
continuous regular IV insulin infusion at 0.1 units/kg/hr to correct hyperglycemia and ketosis.
Why Wrong: A uses 0.45% NaCl, which is initiated after initial 0.9% NaCl resuscitation. B provides dextrose,
worsening hyperglycemia, and NPH is not given IV. D uses a long-acting insulin and a fluid not standard for
DKA initial resuscitation.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 35: Endocrine Disorders; ADA 2025
DKA Management.
6. A client with cirrhosis develops asterixis. Which laboratory value is most closely associated
with this finding?
A. Serum ammonia 180 mcg/dL.
B. Total bilirubin 8.2 mg/dL.
C. Albumin 2.1 g/dL.
D. INR 3.4.
Correct Answer: A. Serum ammonia 180 mcg/dL.
Rationale: Asterixis (flapping tremor) is a hallmark of hepatic encephalopathy, which results from elevated
serum ammonia levels that cross the blood-brain barrier and impair neurotransmission.
Why Wrong: B indicates jaundice and cholestasis. C indicates impaired protein synthesis. D indicates impaired
coagulation. While all are abnormal in cirrhosis, only ammonia correlates with asterixis.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 36: Gastrointestinal Disorders.
7. A client receiving a blood transfusion develops fever, chills, and low back pain 15 minutes after
the transfusion begins. Which action should the nurse take first?
A. Slow the transfusion rate and notify the health care provider.
B. Stop the transfusion and maintain IV access with 0.9% NaCl.
C. Administer acetaminophen and continue the transfusion.
D. Assess vital signs and recheck the blood label.
Correct Answer: B. Stop the transfusion and maintain IV access with 0.9% NaCl.
Rationale: These symptoms indicate an acute hemolytic transfusion reaction. The priority is to immediately
stop the transfusion, maintain IV patency with 0.9% NaCl using new tubing, and notify the provider and blood
bank.
Edition
150 Verified Questions & Answers with Rationales
Aligned with the 2026/2027 Elsevier HESI Curriculum,
Next Generation NCLEX (NGN) Standards, and Current Evidence-Based Clinical Guidelines
Official Question Count: 150 | Status: Verified | Format: Actual Exam
,Key Features
✓ Comprehensive NCLEX-style content across all major nursing disciplines.
✓ Next Generation NCLEX (NGN) Clinical Judgment Measurement Model (CJMM) application in item
scenarios.
✓ Advanced medical-surgical, maternal-newborn, pediatric, and psychiatric nursing integration.
✓ Evidence-based standards for patient safety, infection control, and quality improvement.
✓ Leadership, management, and community health nursing principles applied across care settings.
Updates for 2026
Full integration of the NCSBN Clinical Judgment Measurement Model (CJMM) across all HESI exit scenarios,
emphasizing layered thinking: Recognize Cues, Analyze Cues, Prioritize Hypotheses, Generate Solutions, Take
Action, and Evaluate Outcomes.
Updated 2026 National Patient Safety Goals (NPSGs) for high-alert medications, fall prevention, and preventing
health care-associated infections, with revised hand-off communication standards.
Revised Elsevier clinical reasoning frameworks for managing complex, multi-system patient scenarios,
incorporating the latest sepsis, stroke, and acute coronary syndrome clinical standards.
Abstract
This document presents a comprehensive 150-question actual exam modeled on the 2026/2027 Elsevier HESI
Comprehensive Exit Exam blueprint. It integrates foundational nursing skills with advanced medical-surgical
concepts, maternal-newborn and pediatric care, mental health and psychosocial management, pharmacology
and safe medication administration, and leadership and community health principles. Each item is constructed
using the Next Generation NCLEX Clinical Judgment Measurement Model, requiring the test-taker to recognize
and analyze clinical cues, prioritize hypotheses, generate solutions, take action, and evaluate outcomes. The
questions reflect the critical clinical judgment required for NCLEX success and program completion, and are
accompanied by rationales, distractor analysis, and references drawn from the 2026 Elsevier HESI curriculum
and current evidence-based clinical standards. This resource is designed to evaluate readiness across the breadth
of nursing knowledge expected of a graduate-level registered nurse entering contemporary practice.
Keywords
HESI Exit Exam, Comprehensive Predictor, RN Nursing, NGN, Clinical Judgment, Medical-Surgical,
Pharmacology, Maternal-Newborn, Patient Safety, NCLEX Readiness
Content Area Overview
Content Area Questions Key Topics Weight
Medical-Surgical Nursing 45 Cardiovascular, respiratory, renal, GI, endocrine, 30%
neurologic, hematologic, musculoskeletal
Maternal-Newborn & Pediatric 30 Antepartum, intrapartum, postpartum, newborn, 20%
Nursing pediatric acute and chronic conditions
Mental Health & Psychosocial 25 Anxiety, mood, psychotic, personality, eating, 17%
Care substance use, trauma-related disorders
Pharmacology & Safe 30 Drug classifications, side effects, interactions, IV 20%
Administration therapy, high-alert medications
Leadership, Community 20 Delegation, prioritization, QI, public health, NGN 13%
Health & NGN Case Studies multi-system clinical judgment scenarios
, TOTAL 150 Comprehensive RN readiness across all 100%
domains
Examination Questions
Domain: Medical-Surgical Nursing
1. A 68-year-old client with heart failure is receiving furosemide 40 mg IV. Which finding best
indicates the medication is having the desired therapeutic effect?
A. Serum potassium increases from 3.2 to 4.0 mEq/L.
B. Urine output increases to 80 mL/hr and dyspnea decreases.
C. Blood pressure rises from 96/60 to 130/84 mmHg.
D. Heart rate decreases from 110 to 64 beats/min.
Correct Answer: B. Urine output increases to 80 mL/hr and dyspnea decreases.
Rationale: Furosemide is a loop diuretic whose primary therapeutic goal in heart failure is reduction of
preload through fluid removal, which is demonstrated by increased urine output and relief of pulmonary
congestion (decreased dyspnea).
Why Wrong: A reflects potassium replacement, not furosemide action (it actually lowers potassium). C reflects
a vasopressor effect, not a diuretic effect. D reflects rate control (e.g., digoxin or beta-blocker), not diuresis.
Reference: Elsevier HESI Comprehensive Review for the NCLEX-RN Examination, 8th ed. (2026), Ch. 30:
Cardiovascular Disorders.
2. A client admitted with acute coronary syndrome reports chest pain rated 8/10. Oxygen is
applied at 2 L/min. Which medication should the nurse administer first?
A. Aspirin 325 mg chewable orally.
B. Nitroglycerin 0.4 mg sublingual.
C. Morphine 4 mg IV push.
D. Atorvastatin 80 mg orally.
Correct Answer: B. Nitroglycerin 0.4 mg sublingual.
Rationale: Sublingual nitroglycerin is the first-line agent for active ischemic chest pain because it acts within
1 to 3 minutes to dilate coronary arteries and reduce myocardial oxygen demand.
Why Wrong: Aspirin should be given promptly but after immediate pain relief is initiated. Morphine is
reserved for pain unresponsive to nitroglycerin. Atorvastatin is long-term therapy, not acute pain relief.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 30: Cardiovascular Disorders; ACC/AHA
2025 ACS Guideline.
3. A client with chronic obstructive pulmonary disease (COPD) has an arterial blood gas (ABG)
result of pH 7.32, PaCO2 58 mmHg, PaO2 62 mmHg, HCO3 30 mEq/L. Which interpretation is
correct?
A. Respiratory alkalosis with metabolic compensation.
B. Uncompensated metabolic acidosis.
C. Partially compensated respiratory acidosis.
D. Fully compensated metabolic alkalosis.
Correct Answer: C. Partially compensated respiratory acidosis.
Rationale: Low pH (acidosis), elevated PaCO2 (respiratory cause), and elevated HCO3 (kidneys retaining
bicarbonate to compensate) indicate partially compensated respiratory acidosis, a classic finding in COPD
exacerbation.
Why Wrong: A is incorrect because PaCO2 is elevated, not low. B is incorrect because the primary cause is
respiratory, not metabolic. D is incorrect because pH is still below normal, so compensation is not complete.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 27: Respiratory Disorders.
4. A nurse is caring for a client with a chest tube connected to a water-seal chamber. The nurse
observes constant bubbling in the water-seal chamber. Which action should the nurse take?
, A. Document the finding as expected.
B. Check the system for an air leak.
C. Clamp the chest tube immediately.
D. Add more water to the suction control chamber.
Correct Answer: B. Check the system for an air leak.
Rationale: Constant bubbling in the water-seal chamber indicates an air leak in the system (or from the
patient), which must be located and addressed. Intermittent bubbling with exhalation is normal, but
continuous bubbling is not.
Why Wrong: A is incorrect because continuous bubbling is abnormal. C clamping can cause tension
pneumothorax and is contraindicated. D addresses the suction control chamber, not the water-seal chamber
leak.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 27: Respiratory Disorders; AARC 2025
Chest Tube Guidelines.
5. A client with type 1 diabetes presents with blood glucose 612 mg/dL, deep rapid respirations,
and a fruity breath odor. Which IV fluid and insulin protocol should the nurse anticipate?
A. 0.45% NaCl with regular insulin infusion at 0.1 units/kg/hr.
B. D5W with NPH insulin 10 units IV push.
C. 0.9% NaCl with regular insulin infusion at 0.1 units/kg/hr.
D. Lactated Ringer's with glargine insulin 20 units subcutaneously.
Correct Answer: C. 0.9% NaCl with regular insulin infusion at 0.1 units/kg/hr.
Rationale: Diabetic ketoacidosis (DKA) is treated with 0.9% NaCl for rapid volume restoration and a
continuous regular IV insulin infusion at 0.1 units/kg/hr to correct hyperglycemia and ketosis.
Why Wrong: A uses 0.45% NaCl, which is initiated after initial 0.9% NaCl resuscitation. B provides dextrose,
worsening hyperglycemia, and NPH is not given IV. D uses a long-acting insulin and a fluid not standard for
DKA initial resuscitation.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 35: Endocrine Disorders; ADA 2025
DKA Management.
6. A client with cirrhosis develops asterixis. Which laboratory value is most closely associated
with this finding?
A. Serum ammonia 180 mcg/dL.
B. Total bilirubin 8.2 mg/dL.
C. Albumin 2.1 g/dL.
D. INR 3.4.
Correct Answer: A. Serum ammonia 180 mcg/dL.
Rationale: Asterixis (flapping tremor) is a hallmark of hepatic encephalopathy, which results from elevated
serum ammonia levels that cross the blood-brain barrier and impair neurotransmission.
Why Wrong: B indicates jaundice and cholestasis. C indicates impaired protein synthesis. D indicates impaired
coagulation. While all are abnormal in cirrhosis, only ammonia correlates with asterixis.
Reference: Elsevier HESI Comprehensive Review, 8th ed. (2026), Ch. 36: Gastrointestinal Disorders.
7. A client receiving a blood transfusion develops fever, chills, and low back pain 15 minutes after
the transfusion begins. Which action should the nurse take first?
A. Slow the transfusion rate and notify the health care provider.
B. Stop the transfusion and maintain IV access with 0.9% NaCl.
C. Administer acetaminophen and continue the transfusion.
D. Assess vital signs and recheck the blood label.
Correct Answer: B. Stop the transfusion and maintain IV access with 0.9% NaCl.
Rationale: These symptoms indicate an acute hemolytic transfusion reaction. The priority is to immediately
stop the transfusion, maintain IV patency with 0.9% NaCl using new tubing, and notify the provider and blood
bank.
