HESI Exit PN | HESI Exit PN Exam Version 1
Comprehensive Review Questions with Correct
Answers and Expert Explanation for Each Question
1. A client taking digoxin (Lanoxin) reports experiencing nausea, vomiting, and visual
disturbances described as yellow halos. Which action should the nurse take first?
A. Administer the next scheduled dose of digoxin
B. Document the findings as a common side effect of the medication
C. Provide the client with a light snack to settle the stomach
D. Check the client’s apical pulse and notify the healthcare provider
Correct Answer: D
Expert Explanation: The reported symptoms are classic indicators of digoxin
toxicity which can be life-threatening. The nurse must immediately assess the apical
pulse for bradycardia or arrhythmias. Notifying the healthcare provider is necessary
to obtain a serum digoxin level and determine if the medication should be withheld.
Administering another dose would worsen the toxicity and place the client at risk
for cardiac arrest. Monitoring for these signs is a critical component of safe
pharmacological nursing practice.
2. The nurse is caring for a client with a history of Clostridium difficile (C. diff). Which
infection control measure is most appropriate?
A. Washing hands with soap and water after patient contact
,B. Wearing an N95 respirator during client care
C. Using an alcohol-based hand rub after leaving the room
D. Ensuring the client is in a semi-private room with a roommate
Correct Answer: A
Expert Explanation: C. diff spores are resistant to alcohol-based hand sanitizers,
making soap and water mandatory for removal. Hand hygiene is the single most
effective way to prevent the spread of this infection in the clinical setting. The client
should be placed in contact precautions which require gloves and a gown. A private
room is preferred to prevent cross-contamination between patients. Understanding
specific pathogen characteristics allows the nurse to implement the correct
transmission-based precautions.
3. A client is 4 hours postoperative after a total hip replacement. Which nursing
intervention is essential to prevent dislocation of the prosthesis?
A. Encourage the client to cross their legs for comfort
B. Place an abductor pillow between the client’s legs
C. Keep the client’s bed in a high-Fowler’s position
D. Assist the client to flex their hip more than 90 degrees
Correct Answer: B
,Expert Explanation: An abductor pillow maintains the hip in an abducted position
to prevent the ball from popping out of the socket. Crossing the legs or flexing the
hip beyond 90 degrees significantly increases the risk of prosthesis dislocation.
High-Fowler’s position is contraindicated because it causes excessive hip flexion.
The nurse must educate the client on these movement restrictions to ensure a
successful recovery. Proper positioning is a fundamental aspect of postoperative
orthopedic nursing care.
4. The nurse is preparing to administer glargine (Lantus) insulin to a client with type 1
diabetes. Which action is correct regarding this type of insulin?
A. Administer glargine at the same time each day without mixing
B. Administer glargine 15 minutes before breakfast
C. Mix glargine with regular insulin in the same syringe
D. Shake the vial vigorously before drawing up the dose
Correct Answer: A
Expert Explanation: Glargine is a long-acting insulin that must never be mixed with
other insulins in the same syringe. Mixing glargine can alter its absorption rate and
peak, leading to unpredictable blood glucose levels. It provides a steady basal rate of
insulin over 24 hours and typically has no peak. Shaking the vial can create bubbles
, and lead to inaccurate dosing; instead, it should be gently rolled. Consistency in
administration timing helps maintain stable glycemic control for the client.
5. A nurse is reviewing laboratory results for a client receiving warfarin (Coumadin).
Which value indicates the medication is in the therapeutic range?
A. INR of 2.5
B. INR of 1.0
C. PTT of 60 seconds
D. Platelet count of 100,000
Correct Answer: A
Expert Explanation: The therapeutic range for International Normalized Ratio
(INR) for a client on warfarin is generally between 2.0 and 3.0. An INR of 1.0 is
considered a normal baseline for a person not taking anticoagulants and is
subtherapeutic for this client. PTT is used to monitor heparin therapy rather than
warfarin therapy. Platelet counts measure clotting potential but are not the primary
monitoring tool for warfarin’s effectiveness. Maintaining the therapeutic INR range
is vital to prevent both clots and excessive bleeding.
6. Which task should the Practical Nurse (PN) delegate to the Unlicensed Assistive
Personnel (UAP)?
A. Teaching a client how to use an incentive spirometer
Comprehensive Review Questions with Correct
Answers and Expert Explanation for Each Question
1. A client taking digoxin (Lanoxin) reports experiencing nausea, vomiting, and visual
disturbances described as yellow halos. Which action should the nurse take first?
A. Administer the next scheduled dose of digoxin
B. Document the findings as a common side effect of the medication
C. Provide the client with a light snack to settle the stomach
D. Check the client’s apical pulse and notify the healthcare provider
Correct Answer: D
Expert Explanation: The reported symptoms are classic indicators of digoxin
toxicity which can be life-threatening. The nurse must immediately assess the apical
pulse for bradycardia or arrhythmias. Notifying the healthcare provider is necessary
to obtain a serum digoxin level and determine if the medication should be withheld.
Administering another dose would worsen the toxicity and place the client at risk
for cardiac arrest. Monitoring for these signs is a critical component of safe
pharmacological nursing practice.
2. The nurse is caring for a client with a history of Clostridium difficile (C. diff). Which
infection control measure is most appropriate?
A. Washing hands with soap and water after patient contact
,B. Wearing an N95 respirator during client care
C. Using an alcohol-based hand rub after leaving the room
D. Ensuring the client is in a semi-private room with a roommate
Correct Answer: A
Expert Explanation: C. diff spores are resistant to alcohol-based hand sanitizers,
making soap and water mandatory for removal. Hand hygiene is the single most
effective way to prevent the spread of this infection in the clinical setting. The client
should be placed in contact precautions which require gloves and a gown. A private
room is preferred to prevent cross-contamination between patients. Understanding
specific pathogen characteristics allows the nurse to implement the correct
transmission-based precautions.
3. A client is 4 hours postoperative after a total hip replacement. Which nursing
intervention is essential to prevent dislocation of the prosthesis?
A. Encourage the client to cross their legs for comfort
B. Place an abductor pillow between the client’s legs
C. Keep the client’s bed in a high-Fowler’s position
D. Assist the client to flex their hip more than 90 degrees
Correct Answer: B
,Expert Explanation: An abductor pillow maintains the hip in an abducted position
to prevent the ball from popping out of the socket. Crossing the legs or flexing the
hip beyond 90 degrees significantly increases the risk of prosthesis dislocation.
High-Fowler’s position is contraindicated because it causes excessive hip flexion.
The nurse must educate the client on these movement restrictions to ensure a
successful recovery. Proper positioning is a fundamental aspect of postoperative
orthopedic nursing care.
4. The nurse is preparing to administer glargine (Lantus) insulin to a client with type 1
diabetes. Which action is correct regarding this type of insulin?
A. Administer glargine at the same time each day without mixing
B. Administer glargine 15 minutes before breakfast
C. Mix glargine with regular insulin in the same syringe
D. Shake the vial vigorously before drawing up the dose
Correct Answer: A
Expert Explanation: Glargine is a long-acting insulin that must never be mixed with
other insulins in the same syringe. Mixing glargine can alter its absorption rate and
peak, leading to unpredictable blood glucose levels. It provides a steady basal rate of
insulin over 24 hours and typically has no peak. Shaking the vial can create bubbles
, and lead to inaccurate dosing; instead, it should be gently rolled. Consistency in
administration timing helps maintain stable glycemic control for the client.
5. A nurse is reviewing laboratory results for a client receiving warfarin (Coumadin).
Which value indicates the medication is in the therapeutic range?
A. INR of 2.5
B. INR of 1.0
C. PTT of 60 seconds
D. Platelet count of 100,000
Correct Answer: A
Expert Explanation: The therapeutic range for International Normalized Ratio
(INR) for a client on warfarin is generally between 2.0 and 3.0. An INR of 1.0 is
considered a normal baseline for a person not taking anticoagulants and is
subtherapeutic for this client. PTT is used to monitor heparin therapy rather than
warfarin therapy. Platelet counts measure clotting potential but are not the primary
monitoring tool for warfarin’s effectiveness. Maintaining the therapeutic INR range
is vital to prevent both clots and excessive bleeding.
6. Which task should the Practical Nurse (PN) delegate to the Unlicensed Assistive
Personnel (UAP)?
A. Teaching a client how to use an incentive spirometer
