HESI EXIT NGN, HESI RN Exit Exam (2025)
A pt presses the call bell and requests pain medication for a severe headache. To assess the quality of
the pt. Pain, which approach should the nurse use? - (correct Answer) - Ask the patient to describe the
pain
The nurse is wearing personal protective equipment while caring for a pt. When exiting the room, which
PPE should be removed first? - (correct Answer) - Gloves
An older pt is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall
at home. The daughter, who has power of attorney, has brought the client's prescriptions. Which
information should the nurse provide first when reporting to the healthcare provider using SBAR
communication? - (correct Answer) - Increasing confusion of the pt.
A pt tells the nurse about working out with a personal trainer and swimming three times a week in an
effort to lose weight and sleep better. The pt states that it still is taking hours to fall asleep at night.
Which action should the nurse implement? - (correct Answer) - Ask the pt for a description of the
exercise schedule that is being followed
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering from
Guillain-Barre syndrome about home. Which actions should the nurse include when providing discharge
teaching to the pt and spouse? SATA - (correct Answer) - -review safe transfer strategies
-develop a nutritional plan
-help identify community support
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which
outcome indicates that the program was effective? - (correct Answer) - pt who develop disease
complications promptly received rehabilitation
The nurse has received funding to design a health promotion project for African American women who
are at risk for developing breast cancer. Which resource is most important in designing this program? -
(correct Answer) - participation of community leaders in planning the program
A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries occurred.
The healthcare provider instructs the nurse to avoid auto contamination when performing dressing
changes. Which intervention is most important for the nurse to implement? - (correct Answer) - use
gown, mask, and gloves with dressing changes
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are infusing. The
pt is sedated but responds to instructions. After changing positions, the pt complains of pain at the right
groin insertion site. What action should the nurse implement? - (correct Answer) - Stimulate the pt to
take deep breaths
Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most important for
,the nurse to obtain? - (correct Answer) - upper body muscle strength
While the nurse is assessing an older pt fall risk, the pt reports living at home alone and never falling.
Which action should the nurse take? - (correct Answer) - Continue to obtain pt data needed to complete
the fall risk survey
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is weak and
begins coughing while attempting to drink through a straw. Which intervention should the nurse
implement? - (correct Answer) - Teach coughing and deep breathing exercises
The nurse is teaching the pt about home care after surgery for an ileal conduit placement. When
reviewing the information, which statement should the nurse recognize as needing additional
education? - (correct Answer) - Empty the pouch when it is half full.
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum. Which
action is most important for the nurse to implement? - (correct Answer) - initiate prescribed IV fluids
A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the nurse
should ensure that the pt bed is in which position? - (correct Answer) - Picture with the bed sitting up
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous
questions about the procedure. In preparing the pt for the procedure, which intervention has the highest
priority? - (correct Answer) - Instruct pt to write down questions
While caring for a pt post operative dressing, the nurse observes purulent drainage at the wound. Before
reporting this finding to the provider, the nurse should review which of the pt lab values? - (correct
Answer) - culture for sensitive organisms
A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every
12hrs. When the client requests an afternoon snack, which dietary choice should the nurse provide? -
(correct Answer) - Cinnamon apple sauce
An older male reporting abd pain is admitted from a facility. It has been 7 days since his last BM and his
abd is distended, and he just vomited 150ml of dark brown emesis. In what order should the nurse
implement these interventions? - (correct Answer) - Send emesis to lab
Elevate HOB
complete focused assessment
offers PRN pain meds
A patient who recently received a prescription for ramelteon to treat sleep deprivation reports
experiencing several side effects since taking the med. Which side effect should the nurse report to the
healthcare provider? - (correct Answer) - Somnambulism
A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which
information in the client's history requires follow up by the nurse? - (correct Answer) - take metformin
for type 2 diabetes
The nurse should withhold which medication if the client's serum potassium level is 6.2 mEq/? - (correct
,Answer) - Spironolactone
A nurse receives a report on a pt who is four hours post-total abdominal hysterectomy. The previous
nurse reports that it was necessary to change the client's perineal pad hourly and that it is again
saturated. The previous nurse also reports that the client's urinary output has decreased. Which action
should the nurse implement first? - (correct Answer) - Assess for weakness or dizziness
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the pt,
in which sequence should the nurse complete these actions? - (correct Answer) - -Observe breathing
patterns
-assess blood pressure
-measure body temp
-palpate for pedal edema
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
information in the admission assessment is relevant to the nurse's plan for taking the blood pressure
reading? SATA - (correct Answer) - Blurred Vision
Flat Affect
frequent syncope
After administering a proton pump inhibitor, which action should the nurse take to evaluate the
effectiveness of the medication? - (correct Answer) - Ask the pt about gastrointestinal pain
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the
medication, which serum laboratory value most important for the nurse to monitor - (correct Answer) -
platelet count
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan,
the nurse should teach the parents to report which sign of overdose? - (correct Answer) - Bradycardia
The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel working on
a rehab unit. The UAP asks the nurse how to safely move a physically disabled pt from the... wheelchair
to the bed. Which action should the nurse recommend? - (correct Answer) - Place the pt locked
wheelchair on the pt strong side next to the bed
The nurse has completed the diet teaching of a client who is being discharged following tx of a leg
wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the pt
indicates that the teaching was effective? - (correct Answer) - A tuna fish sandwich with chips and ice
cream
When conducting diet teaching for a pt who was dx with a myocardial infarction, which snack foods
should the nurse encourage the pt to eat? SATA - (correct Answer) - Fresh Turkey slices and berries
chick bouillon soup and toast
raw unsalted almonds and apples
, A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement
first? - (correct Answer) - Observe the appearance of the stool
A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan
of care? - (correct Answer) - Risk for injury related to vertigo
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the
charge nurse implement? - (correct Answer) - Suggest the nurse use 20g needle
A nurse working on an Endocrine Unit should see which client first? - (correct Answer) - A pt taking
corticosteroids who has become disoriented in the last two hours.
After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creatinine
clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should the nurse
implement? - (correct Answer) - Notify the healthcare provider of the results
An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 110, and RR of
24 breaths/min. Which additional finding is most important to report to the healthcare provider? -
(correct Answer) - Serum Creatinine of 2mg/dl
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that
her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in
two weeks. What actions should the nurse take? - (correct Answer) - Explain that this is normal
recreation and can be assessed at the next visit.
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal
discharge. Which action should the nurse take first? - (correct Answer) - begin continuous fetal
monitoring
The mother of a 2 day old infant girl expresses concern about a flea bite type rash on her daughter's
body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back,
buttocks, and abdomen. Which explanation should the nurse offer? - (correct Answer) - This is a
common newborn rash that will resolve after several days.
When assessing a recently delivered mom that her vaginal bleeding is more than expected. Which factor
in this history is related to this finding? - (correct Answer) - She is a gravid 6 para 5.
The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After
administering surfactant, which assessment is most important for the nurse to monitor? - (correct
Answer) - Arterial blood gas
A pt who gave birth 48 hours ago has decided to bottle feed teh infant. During the assessment, the nurse
observes that both breasts are swollen, warm and tender on palpation. Which instruction should the
nurse provide? - (correct Answer) - Apply ice to the breast for comfort.
The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair
for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6
months postoperatively to prevent infective endocarditis. What information is most important for the
nurse discuss with the parents about the child's recovery and prevention of IE. - (correct Answer) - Brush
the child's teeth everyday and ensure the child receives regular dental follow up.
A pt presses the call bell and requests pain medication for a severe headache. To assess the quality of
the pt. Pain, which approach should the nurse use? - (correct Answer) - Ask the patient to describe the
pain
The nurse is wearing personal protective equipment while caring for a pt. When exiting the room, which
PPE should be removed first? - (correct Answer) - Gloves
An older pt is brought to the ED with a sudden onset of confusion that occurred after experiencing a fall
at home. The daughter, who has power of attorney, has brought the client's prescriptions. Which
information should the nurse provide first when reporting to the healthcare provider using SBAR
communication? - (correct Answer) - Increasing confusion of the pt.
A pt tells the nurse about working out with a personal trainer and swimming three times a week in an
effort to lose weight and sleep better. The pt states that it still is taking hours to fall asleep at night.
Which action should the nurse implement? - (correct Answer) - Ask the pt for a description of the
exercise schedule that is being followed
2 days prior to discharge from the rehab facility, the nurse is teaching a pt who is recovering from
Guillain-Barre syndrome about home. Which actions should the nurse include when providing discharge
teaching to the pt and spouse? SATA - (correct Answer) - -review safe transfer strategies
-develop a nutritional plan
-help identify community support
The nurse implements a tertiary prevention program for type 2 diabetes in a rural health clinic. Which
outcome indicates that the program was effective? - (correct Answer) - pt who develop disease
complications promptly received rehabilitation
The nurse has received funding to design a health promotion project for African American women who
are at risk for developing breast cancer. Which resource is most important in designing this program? -
(correct Answer) - participation of community leaders in planning the program
A pt with multiple injuries is being treated in the burn trauma unit just hours after the injuries occurred.
The healthcare provider instructs the nurse to avoid auto contamination when performing dressing
changes. Which intervention is most important for the nurse to implement? - (correct Answer) - use
gown, mask, and gloves with dressing changes
A pt is recovering in the critical care unit following a cardiac cath. IV nitro and heparin are infusing. The
pt is sedated but responds to instructions. After changing positions, the pt complains of pain at the right
groin insertion site. What action should the nurse implement? - (correct Answer) - Stimulate the pt to
take deep breaths
Prior to obtaining a trapeze bar for a pt with limited mobility, which pt assessment is most important for
,the nurse to obtain? - (correct Answer) - upper body muscle strength
While the nurse is assessing an older pt fall risk, the pt reports living at home alone and never falling.
Which action should the nurse take? - (correct Answer) - Continue to obtain pt data needed to complete
the fall risk survey
The nurse is feeding an older adult who was admitted with aspiration pneumonia. The pt is weak and
begins coughing while attempting to drink through a straw. Which intervention should the nurse
implement? - (correct Answer) - Teach coughing and deep breathing exercises
The nurse is teaching the pt about home care after surgery for an ileal conduit placement. When
reviewing the information, which statement should the nurse recognize as needing additional
education? - (correct Answer) - Empty the pouch when it is half full.
A 12 week gestation is admitted to the antepartum unit with a dx of hyperemesis gravidarum. Which
action is most important for the nurse to implement? - (correct Answer) - initiate prescribed IV fluids
A pt with dyspnea is being admitted to the medical unit. To best prepare for the pt arrival, the nurse
should ensure that the pt bed is in which position? - (correct Answer) - Picture with the bed sitting up
A pt who is scheduled for a bronchoscopy in the morning is anxious and asking the nurse numerous
questions about the procedure. In preparing the pt for the procedure, which intervention has the highest
priority? - (correct Answer) - Instruct pt to write down questions
While caring for a pt post operative dressing, the nurse observes purulent drainage at the wound. Before
reporting this finding to the provider, the nurse should review which of the pt lab values? - (correct
Answer) - culture for sensitive organisms
A pt with a lower respiratory tract infection receives a prescription for ciprofloxacin 500mg PO every
12hrs. When the client requests an afternoon snack, which dietary choice should the nurse provide? -
(correct Answer) - Cinnamon apple sauce
An older male reporting abd pain is admitted from a facility. It has been 7 days since his last BM and his
abd is distended, and he just vomited 150ml of dark brown emesis. In what order should the nurse
implement these interventions? - (correct Answer) - Send emesis to lab
Elevate HOB
complete focused assessment
offers PRN pain meds
A patient who recently received a prescription for ramelteon to treat sleep deprivation reports
experiencing several side effects since taking the med. Which side effect should the nurse report to the
healthcare provider? - (correct Answer) - Somnambulism
A pt is scheduled for a spiral CT scan with contrast to evaluate for pulmonary embolism. Which
information in the client's history requires follow up by the nurse? - (correct Answer) - take metformin
for type 2 diabetes
The nurse should withhold which medication if the client's serum potassium level is 6.2 mEq/? - (correct
,Answer) - Spironolactone
A nurse receives a report on a pt who is four hours post-total abdominal hysterectomy. The previous
nurse reports that it was necessary to change the client's perineal pad hourly and that it is again
saturated. The previous nurse also reports that the client's urinary output has decreased. Which action
should the nurse implement first? - (correct Answer) - Assess for weakness or dizziness
A pt who is admitted for primary hypothyroidism has early signs of myxedema coma. In assessing the pt,
in which sequence should the nurse complete these actions? - (correct Answer) - -Observe breathing
patterns
-assess blood pressure
-measure body temp
-palpate for pedal edema
The nurse is taking the blood pressure measurement of a client with Parkinson's disease. Which
information in the admission assessment is relevant to the nurse's plan for taking the blood pressure
reading? SATA - (correct Answer) - Blurred Vision
Flat Affect
frequent syncope
After administering a proton pump inhibitor, which action should the nurse take to evaluate the
effectiveness of the medication? - (correct Answer) - Ask the pt about gastrointestinal pain
A pt is receiving enoxaparin 30 mg subcutaneously twice a day. In assessing for adverse effects of the
medication, which serum laboratory value most important for the nurse to monitor - (correct Answer) -
platelet count
A pediatric client is taking the beta-adrenergic blocking agent propranolol. In developing a teaching plan,
the nurse should teach the parents to report which sign of overdose? - (correct Answer) - Bradycardia
The nurse is demonstrating correct transfer procedures to the unlicensed assistive personnel working on
a rehab unit. The UAP asks the nurse how to safely move a physically disabled pt from the... wheelchair
to the bed. Which action should the nurse recommend? - (correct Answer) - Place the pt locked
wheelchair on the pt strong side next to the bed
The nurse has completed the diet teaching of a client who is being discharged following tx of a leg
wound. A high protein diet is encouraged to promote wound healing. Which lunch choice by the pt
indicates that the teaching was effective? - (correct Answer) - A tuna fish sandwich with chips and ice
cream
When conducting diet teaching for a pt who was dx with a myocardial infarction, which snack foods
should the nurse encourage the pt to eat? SATA - (correct Answer) - Fresh Turkey slices and berries
chick bouillon soup and toast
raw unsalted almonds and apples
, A pt taking clopidogrel reports the onset of diarrhea. Which nursing action should the nurse implement
first? - (correct Answer) - Observe the appearance of the stool
A pt is dx with Meniere's disease. Which problem should the nurse identify as most important in the plan
of care? - (correct Answer) - Risk for injury related to vertigo
A new nurse preparing to irrigate an IV catheter is attaching a 24 gauge needle. Which action should the
charge nurse implement? - (correct Answer) - Suggest the nurse use 20g needle
A nurse working on an Endocrine Unit should see which client first? - (correct Answer) - A pt taking
corticosteroids who has become disoriented in the last two hours.
After an older pt receives tx for drug toxicity the healthcare provider prescribes a 24 hr creatinine
clearance, the nurse notes that the pt serum creatinine is 0.3mg. Which action should the nurse
implement? - (correct Answer) - Notify the healthcare provider of the results
An older adult pt with Systemic inflammatory syndrome (SIRS) has a temp of 101.8, HR of 110, and RR of
24 breaths/min. Which additional finding is most important to report to the healthcare provider? -
(correct Answer) - Serum Creatinine of 2mg/dl
A pt in the third trimester of pregnancy reports that she feels some lumpy places in her breasts and that
her nipples sometimes leak a yellowish fluid. She has an appointment with her healthcare provider in
two weeks. What actions should the nurse take? - (correct Answer) - Explain that this is normal
recreation and can be assessed at the next visit.
A pt presents to the labor and delivery unit with a report of leaking fluid that is greenish-brown vaginal
discharge. Which action should the nurse take first? - (correct Answer) - begin continuous fetal
monitoring
The mother of a 2 day old infant girl expresses concern about a flea bite type rash on her daughter's
body. The nurse identifies a pink papular rash with vesicles superimposed over the thorax, back,
buttocks, and abdomen. Which explanation should the nurse offer? - (correct Answer) - This is a
common newborn rash that will resolve after several days.
When assessing a recently delivered mom that her vaginal bleeding is more than expected. Which factor
in this history is related to this finding? - (correct Answer) - She is a gravid 6 para 5.
The nurse is caring for a preterm newborn with nasal flaring, grunting, and sternal retractions. After
administering surfactant, which assessment is most important for the nurse to monitor? - (correct
Answer) - Arterial blood gas
A pt who gave birth 48 hours ago has decided to bottle feed teh infant. During the assessment, the nurse
observes that both breasts are swollen, warm and tender on palpation. Which instruction should the
nurse provide? - (correct Answer) - Apply ice to the breast for comfort.
The nurse is providing discharge teaching to the parents of a 13 month old child who underwent repair
for an atrial septal defect. The healthcare provider prescribes aspirin and an antibiotic for the first 6
months postoperatively to prevent infective endocarditis. What information is most important for the
nurse discuss with the parents about the child's recovery and prevention of IE. - (correct Answer) - Brush
the child's teeth everyday and ensure the child receives regular dental follow up.
