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Page | 1
HESI Exit Exam V2 2025
NGN-Style Practice Pack |
200 High-Yield NCLEX
Questions with Rationales
✅ Question 1
A nurse enters the room of a client on contact precautions for Clostridioides difficile (C.
difficile). Which action is most appropriate before exiting the room?
a. Remove gloves and gown, then use alcohol-based hand rub
b. Remove gown, wash hands with soap and water, then remove gloves
c. Remove gloves and gown, then wash hands with soap and water
d. Remove gloves, use alcohol-based rub, and then remove gown
✔ Correct Answer: c. Remove gloves and gown, then wash hands with soap and water
Rationale:
, 2
C. difficile spores resist alcohol-based rubs.
Correct PPE removal order: gloves → gown → wash hands with soap and water.
Prevents healthcare-associated infections (HAIs).
DIF: Apply
Page | 2 TOP: Safety and Infection Control
MSC: Safe and Effective Care Environment – Safety and Infection Control
✅ Question 2
A nurse is caring for a postoperative client who suddenly develops shortness of breath, chest
pain, and anxiety. The nurse suspects a pulmonary embolism. What is the priority action?
a. Notify the healthcare provider
b. Elevate head of bed and administer oxygen
c. Check vital signs
d. Prepare for chest x-ray
✔ Correct Answer: b. Elevate head of bed and administer oxygen
Rationale:
Immediate airway/breathing support follows ABCs.
Oxygenation is critical in PE.
Notification comes after initial stabilization.
DIF: Apply
TOP: Physiological Adaptation
MSC: Safe and Effective Care Environment – Management of Care
✅ Question 3
A client with type 1 diabetes becomes unresponsive. The nurse notes shallow breathing and
fruity breath odor. What is the nurse's next action?
a. Administer insulin
b. Call the Rapid Response Team
c. Start chest compressions
d. Give oral glucose
✔ Correct Answer: b. Call the Rapid Response Team
Rationale:
Unresponsiveness + fruity breath = likely diabetic ketoacidosis (DKA).
Immediate medical attention needed.
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Do not administer insulin or oral glucose without full assessment.
DIF: Analyze
TOP: Physiological Adaptation
MSC: Management of Care
Page | 3
✅ Question 4
A nurse is teaching a client prescribed warfarin. Which statement indicates a need for
further teaching?
a. "I’ll use an electric razor to shave."
b. "I’ll eat a consistent amount of green leafy vegetables."
c. "I will avoid using aspirin unless directed."
d. "I’ll stop taking warfarin if I have a headache."
✔ Correct Answer: d. "I’ll stop taking warfarin if I have a headache."
Rationale:
Clients should not stop anticoagulants abruptly.
Headaches should be reported, not self-treated.
Risk of clotting or stroke increases with abrupt discontinuation.
DIF: Evaluate
TOP: Pharmacological and Parenteral Therapies
MSC: Physiological Integrity – Pharmacological Therapies
✅ Question 5
The nurse is preparing to administer digoxin. Which finding requires immediate
intervention?
a. Heart rate of 88 bpm
b. Client reports nausea
c. Serum potassium level of 3.0 mEq/L
d. Blood pressure of 138/84 mmHg
✔ Correct Answer: c. Serum potassium level of 3.0 mEq/L
Rationale:
Hypokalemia increases risk of digoxin toxicity.
Normal K+ range: 3.5–5.0 mEq/L.
Nausea may also be a sign of early toxicity.
, 4
DIF: Apply
TOP: Reduction of Risk Potential
MSC: Physiological Integrity – Pharmacological Therapies
Page | 4 ✅ Question 6
Which statement by a pregnant client in the third trimester requires immediate follow-up?
a. “I feel mild cramping in my lower abdomen.”
b. “I have a headache that won't go away.”
c. “I get tired more easily these days.”
d. “I noticed I need to urinate frequently again.”
✔ Correct Answer: b. “I have a headache that won't go away.”
Rationale:
Persistent headache may indicate preeclampsia, a medical emergency.
Needs further assessment for BP, proteinuria, etc.
Other options are normal in third trimester.
DIF: Analyze
TOP: Antepartum Care
MSC: Health Promotion and Maintenance
✅ Question 7
A client is receiving IV vancomycin. The nurse notes flushing of the face and neck during
administration. What is the best nursing action?
a. Stop the infusion immediately
b. Administer diphenhydramine
c. Slow the infusion rate
d. Notify the provider of an allergic reaction
✔ Correct Answer: c. Slow the infusion rate
Rationale:
Flushing may indicate "Red Man Syndrome," not a true allergy.
Caused by rapid infusion → slow the rate.
Antihistamines may help, but first slow the drug.
DIF: Apply
TOP: Pharmacological and Parenteral Therapies
MSC: Physiological Integrity – Pharmacological Therapies
Page | 1
HESI Exit Exam V2 2025
NGN-Style Practice Pack |
200 High-Yield NCLEX
Questions with Rationales
✅ Question 1
A nurse enters the room of a client on contact precautions for Clostridioides difficile (C.
difficile). Which action is most appropriate before exiting the room?
a. Remove gloves and gown, then use alcohol-based hand rub
b. Remove gown, wash hands with soap and water, then remove gloves
c. Remove gloves and gown, then wash hands with soap and water
d. Remove gloves, use alcohol-based rub, and then remove gown
✔ Correct Answer: c. Remove gloves and gown, then wash hands with soap and water
Rationale:
, 2
C. difficile spores resist alcohol-based rubs.
Correct PPE removal order: gloves → gown → wash hands with soap and water.
Prevents healthcare-associated infections (HAIs).
DIF: Apply
Page | 2 TOP: Safety and Infection Control
MSC: Safe and Effective Care Environment – Safety and Infection Control
✅ Question 2
A nurse is caring for a postoperative client who suddenly develops shortness of breath, chest
pain, and anxiety. The nurse suspects a pulmonary embolism. What is the priority action?
a. Notify the healthcare provider
b. Elevate head of bed and administer oxygen
c. Check vital signs
d. Prepare for chest x-ray
✔ Correct Answer: b. Elevate head of bed and administer oxygen
Rationale:
Immediate airway/breathing support follows ABCs.
Oxygenation is critical in PE.
Notification comes after initial stabilization.
DIF: Apply
TOP: Physiological Adaptation
MSC: Safe and Effective Care Environment – Management of Care
✅ Question 3
A client with type 1 diabetes becomes unresponsive. The nurse notes shallow breathing and
fruity breath odor. What is the nurse's next action?
a. Administer insulin
b. Call the Rapid Response Team
c. Start chest compressions
d. Give oral glucose
✔ Correct Answer: b. Call the Rapid Response Team
Rationale:
Unresponsiveness + fruity breath = likely diabetic ketoacidosis (DKA).
Immediate medical attention needed.
, 3
Do not administer insulin or oral glucose without full assessment.
DIF: Analyze
TOP: Physiological Adaptation
MSC: Management of Care
Page | 3
✅ Question 4
A nurse is teaching a client prescribed warfarin. Which statement indicates a need for
further teaching?
a. "I’ll use an electric razor to shave."
b. "I’ll eat a consistent amount of green leafy vegetables."
c. "I will avoid using aspirin unless directed."
d. "I’ll stop taking warfarin if I have a headache."
✔ Correct Answer: d. "I’ll stop taking warfarin if I have a headache."
Rationale:
Clients should not stop anticoagulants abruptly.
Headaches should be reported, not self-treated.
Risk of clotting or stroke increases with abrupt discontinuation.
DIF: Evaluate
TOP: Pharmacological and Parenteral Therapies
MSC: Physiological Integrity – Pharmacological Therapies
✅ Question 5
The nurse is preparing to administer digoxin. Which finding requires immediate
intervention?
a. Heart rate of 88 bpm
b. Client reports nausea
c. Serum potassium level of 3.0 mEq/L
d. Blood pressure of 138/84 mmHg
✔ Correct Answer: c. Serum potassium level of 3.0 mEq/L
Rationale:
Hypokalemia increases risk of digoxin toxicity.
Normal K+ range: 3.5–5.0 mEq/L.
Nausea may also be a sign of early toxicity.
, 4
DIF: Apply
TOP: Reduction of Risk Potential
MSC: Physiological Integrity – Pharmacological Therapies
Page | 4 ✅ Question 6
Which statement by a pregnant client in the third trimester requires immediate follow-up?
a. “I feel mild cramping in my lower abdomen.”
b. “I have a headache that won't go away.”
c. “I get tired more easily these days.”
d. “I noticed I need to urinate frequently again.”
✔ Correct Answer: b. “I have a headache that won't go away.”
Rationale:
Persistent headache may indicate preeclampsia, a medical emergency.
Needs further assessment for BP, proteinuria, etc.
Other options are normal in third trimester.
DIF: Analyze
TOP: Antepartum Care
MSC: Health Promotion and Maintenance
✅ Question 7
A client is receiving IV vancomycin. The nurse notes flushing of the face and neck during
administration. What is the best nursing action?
a. Stop the infusion immediately
b. Administer diphenhydramine
c. Slow the infusion rate
d. Notify the provider of an allergic reaction
✔ Correct Answer: c. Slow the infusion rate
Rationale:
Flushing may indicate "Red Man Syndrome," not a true allergy.
Caused by rapid infusion → slow the rate.
Antihistamines may help, but first slow the drug.
DIF: Apply
TOP: Pharmacological and Parenteral Therapies
MSC: Physiological Integrity – Pharmacological Therapies
