HESI RN Exit Exam NGN Latest Version B
2025-2026: Comprehensive Study Guide by Sandra L.
Upchurch and Linda Anne Silvestri - Master the Next
Generation Exam
1. A nurse is reviewing the arterial blood gas (ABG) results of a patient with acute respiratory
distress syndrome (ARDS) who is receiving mechanical ventilation. The results show: pH 7.30,
PaCO2 48 mm Hg, HCO3- 24 mEq/L, PaO2 55 mm Hg. The nurse notes that the patient's plateau
pressure has increased from 25 to 35 cm H2O over the past 2 hours. Which intervention should the
nurse prioritize?
A. Increase the tidal volume to 8 mL/kg ideal body weight.
B. Administer sodium bicarbonate intravenously.
C. Reduce the positive end-expiratory pressure (PEEP) to 5 cm H2O.
D. Notify the provider and prepare for possible bronchoscopy or repositioning of the endotracheal tube.
Answer: D
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2, normal HCO3)
and hypoxemia. The rising plateau pressure indicates decreased lung compliance, which could be due to
worsening ARDS, mucus plugging, or tube malposition. Increasing tidal volume (A) could worsen
barotrauma; sodium bicarbonate (B) is not indicated for acute respiratory acidosis; reducing PEEP (C)
would worsen oxygenation. The priority is to identify the cause of the decreased compliance, so notifying
the provider and assessing for obstruction or tube issues is essential.
2. A patient with type 2 diabetes mellitus is admitted for a total knee arthroplasty. The patient's
home medications include metformin 1000 mg twice daily, glipizide 10 mg daily, and atorvastatin
20 mg daily. The nurse reviews the preoperative orders. Which order should the nurse question?
A. Hold metformin on the morning of surgery.
B. Continue glipizide as scheduled.
C. Administer a preoperative dose of atorvastatin.
D. Start an intravenous infusion of regular insulin at 2 units/hour.
Answer: B
Rationale: Metformin is typically held on the day of surgery due to risk of lactic acidosis (especially with
renal impairment or contrast dye). Atorvastatin is generally continued perioperatively. Starting an
insulin infusion may be appropriate if glucose is elevated. However, glipizide, a sulfonylurea, can cause
hypoglycemia if given on an empty stomach before surgery; it should be held on the morning of surgery.
Therefore, continuing glipizide as scheduled is unsafe and should be questioned.
Page 1
,3. A nurse is caring for a patient with chronic kidney disease stage 4 who is scheduled for an
arteriovenous fistula creation in the left arm. Which assessment finding would be most concerning
and require immediate notification of the healthcare provider?
A. Blood pressure 158/92 mm Hg
B. Serum potassium 5.6 mEq/L
C. Hemoglobin 10.2 g/dL
D. Serum creatinine 3.8 mg/dL
Answer: B
Rationale: In stage 4 CKD, a potassium of 5.6 mEq/L indicates hyperkalemia, which can cause
life-threatening cardiac dysrhythmias and requires immediate intervention (e.g., calcium gluconate,
insulin/glucose). Hypertension (A) is common and may need management but is not immediately critical.
Anemia (C) is typical in CKD and may be treated with erythropoietin but is not emergent. Creatinine of
3.8 (D) is elevated but stable for stage 4. The hyperkalemia poses the highest risk.
4. A patient with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with
acute decompensation. The nurse administers furosemide 80 mg intravenously. One hour later, the
patient's urine output is 50 mL. Which action should the nurse take first?
A. Administer a second dose of furosemide as prescribed.
B. Assess the patient for signs of fluid overload and check renal function.
C. Increase the intravenous fluid rate to promote urine output.
D. Notify the provider of the inadequate response and request a change to a different diuretic.
Answer: B
Rationale: After IV furosemide, a urine output of 50 mL in one hour is low (expected >100 mL). The
nurse should first assess the patient (lung sounds, edema, weight) and check renal function (BUN,
creatinine) to determine if the patient is volume depleted or has renal impairment. Administering
another dose (A) without assessment could cause harm if the patient is hypovolemic. Increasing IV fluids
(C) could worsen heart failure. Notifying the provider (D) is important but assessment should come first.
5. A nurse is providing discharge teaching to a patient who has undergone a laparoscopic
cholecystectomy. Which statement by the patient indicates a need for further teaching?
A. I should avoid heavy lifting for about a week.
B. I can expect some shoulder pain due to the gas used during surgery.
C. I will need to follow a low-fat diet for several weeks.
D. I should report any clay-colored stools to my doctor.
Answer: A
Rationale: After laparoscopic cholecystectomy, patients are typically advised to avoid heavy lifting for
2-4 weeks, not just one week, to prevent hernia formation or wound dehiscence. Shoulder pain (B) from
carbon dioxide irritation is common. A low-fat diet (C) is recommended postoperatively to reduce
digestive discomfort. Clay-colored stools (D) may indicate bile duct obstruction and should be reported.
Therefore, the patient's statement about lifting for only a week is incorrect and requires further teaching.
Page 2
,6. A patient with a diagnosis of schizophrenia is prescribed clozapine. The nurse reviews the
patient's laboratory results: white blood cell count (WBC) 3,200/mm³, absolute neutrophil count
(ANC) 1,200/mm³. Which action should the nurse take?
A. Administer the clozapine as ordered and monitor the patient for side effects.
B. Hold the clozapine and notify the healthcare provider immediately.
C. Administer clozapine with a dose of filgrastim.
D. Request a repeat complete blood count in 24 hours.
Answer: B
Rationale: Clozapine can cause agranulocytosis; the ANC must be monitored. An ANC of 1,200/mm³ is
below the threshold for continuing therapy (typically >1,500 for continuation). The drug should be held
and the provider notified. Administering clozapine (A) could worsen neutropenia. Filgrastim (C) is not a
standard co-administration. Repeating CBC (D) delays necessary intervention. The priority is to stop the
drug and prevent severe neutropenia.
7. A nurse is assessing a patient who returns from a cardiac catheterization via the right femoral
artery. The nurse notes a large hematoma at the insertion site and the right foot is cool and pale
with a capillary refill of 5 seconds. Which action should the nurse perform first?
A. Apply a warm compress to the right foot.
B. Elevate the right leg on pillows.
C. Apply manual pressure to the femoral access site.
D. Notify the healthcare provider immediately.
Answer: C
Rationale: The findings indicate possible retroperitoneal bleeding or arterial occlusion. The priority is to
apply manual pressure to the femoral site to achieve hemostasis and improve perfusion. A warm
compress (A) does not address the bleeding. Elevation (B) is contraindicated as it may reduce arterial
flow further. Notifying the provider (D) is important but should be done while applying pressure.
Immediate action to control bleeding is essential.
8. A nurse is caring for a patient with a diagnosis of pulmonary embolism who is receiving a
heparin infusion. The aPTT result is 98 seconds (normal 25-35 seconds). The patient has no signs of
bleeding. What should the nurse do?
A. Increase the heparin infusion rate by 100 units/hour.
B. Decrease the heparin infusion rate by 100 units/hour.
C. Stop the heparin infusion and administer protamine sulfate.
D. Continue the heparin infusion at the current rate.
Answer: D
Rationale: For pulmonary embolism, the therapeutic aPTT range is typically 1.5-2.5 times the control
(about 60-80 seconds if control is 30, or up to 100 seconds depending on the facility). An aPTT of 98
seconds is within or slightly above therapeutic range but not critically high. Without bleeding, the
infusion should be continued at the current rate. Increasing (A) could cause supratherapeutic levels and
bleeding. Decreasing (B) could lead to subtherapeutic levels. Protamine (C) is for reversal of severe
bleeding, not indicated here.
Page 3
, 9. A patient with a history of opioid use disorder is admitted for a surgical procedure. The patient
is on methadone maintenance therapy (100 mg daily). Which prescription should the nurse
anticipate for postoperative pain management?
A. Continue methadone 100 mg daily and add a nonsteroidal anti-inflammatory drug (NSAID) as needed.
B. Discontinue methadone and start a patient-controlled analgesia (PCA) with morphine.
C. Reduce methadone to 50 mg daily and add hydromorphone for breakthrough pain.
D. Administer naloxone if respiratory depression occurs, and avoid all opioids.
Answer: A
Rationale: Methadone should be continued to prevent withdrawal and maintain stability. For
postoperative pain, multimodal analgesia including NSAIDs and possibly short-acting opioids is
appropriate. Discontinuing methadone (B) would precipitate withdrawal. Reducing methadone (C) is not
necessary and could cause withdrawal. While naloxone (D) is available for overdose, avoiding all
opioids is not realistic for significant surgical pain. Therefore, continuing methadone and adding
NSAIDs is the best approach.
10. A nurse is evaluating the effectiveness of a patient's pain management after surgery. The
patient rates pain as 4 on a 0-10 scale, but is grimacing and holding the incisional area. Which
action should the nurse take?
A. Document the pain score and continue the current plan.
B. Administer additional analgesic as prescribed.
C. Reassess the patient in 30 minutes.
D. Ask the patient why they are grimacing if the pain is only 4.
Answer: B
Rationale: The discrepancy between the verbal pain score and behavioral signs suggests the patient may
be underreporting pain or that the pain is affecting function. The nurse should administer additional
analgesic if prescribed, as the goal is to relieve pain and improve function. Documenting and continuing
(A) ignores the nonverbal cues. Waiting 30 minutes (C) delays relief. Asking the patient (D) may be
confrontational and not therapeutic. The priority is to address the apparent pain.
11. A patient with a history of chronic kidney disease (stage 4) is admitted with hyperkalemia
(serum potassium 6.8 mEq/L) and ECG changes showing peaked T waves. The nurse reviews the
electronic health record and notes the patient is prescribed several medications. Which medication
order should the nurse question as most likely contributing to the hyperkalemia?
A. Spironolactone 25 mg orally daily
B. Furosemide 40 mg intravenously every 12 hours
C. Sodium polystyrene sulfonate 15 g orally every 6 hours
D. Calcium gluconate 10% 10 mL intravenously over 3 minutes
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that can exacerbate hyperkalemia, especially
in patients with renal impairment. Furosemide is a loop diuretic that promotes potassium excretion.
Sodium polystyrene sulfonate and calcium gluconate are treatments for hyperkalemia, not causes.
Page 4
2025-2026: Comprehensive Study Guide by Sandra L.
Upchurch and Linda Anne Silvestri - Master the Next
Generation Exam
1. A nurse is reviewing the arterial blood gas (ABG) results of a patient with acute respiratory
distress syndrome (ARDS) who is receiving mechanical ventilation. The results show: pH 7.30,
PaCO2 48 mm Hg, HCO3- 24 mEq/L, PaO2 55 mm Hg. The nurse notes that the patient's plateau
pressure has increased from 25 to 35 cm H2O over the past 2 hours. Which intervention should the
nurse prioritize?
A. Increase the tidal volume to 8 mL/kg ideal body weight.
B. Administer sodium bicarbonate intravenously.
C. Reduce the positive end-expiratory pressure (PEEP) to 5 cm H2O.
D. Notify the provider and prepare for possible bronchoscopy or repositioning of the endotracheal tube.
Answer: D
Rationale: The ABG shows uncompensated respiratory acidosis (low pH, high PaCO2, normal HCO3)
and hypoxemia. The rising plateau pressure indicates decreased lung compliance, which could be due to
worsening ARDS, mucus plugging, or tube malposition. Increasing tidal volume (A) could worsen
barotrauma; sodium bicarbonate (B) is not indicated for acute respiratory acidosis; reducing PEEP (C)
would worsen oxygenation. The priority is to identify the cause of the decreased compliance, so notifying
the provider and assessing for obstruction or tube issues is essential.
2. A patient with type 2 diabetes mellitus is admitted for a total knee arthroplasty. The patient's
home medications include metformin 1000 mg twice daily, glipizide 10 mg daily, and atorvastatin
20 mg daily. The nurse reviews the preoperative orders. Which order should the nurse question?
A. Hold metformin on the morning of surgery.
B. Continue glipizide as scheduled.
C. Administer a preoperative dose of atorvastatin.
D. Start an intravenous infusion of regular insulin at 2 units/hour.
Answer: B
Rationale: Metformin is typically held on the day of surgery due to risk of lactic acidosis (especially with
renal impairment or contrast dye). Atorvastatin is generally continued perioperatively. Starting an
insulin infusion may be appropriate if glucose is elevated. However, glipizide, a sulfonylurea, can cause
hypoglycemia if given on an empty stomach before surgery; it should be held on the morning of surgery.
Therefore, continuing glipizide as scheduled is unsafe and should be questioned.
Page 1
,3. A nurse is caring for a patient with chronic kidney disease stage 4 who is scheduled for an
arteriovenous fistula creation in the left arm. Which assessment finding would be most concerning
and require immediate notification of the healthcare provider?
A. Blood pressure 158/92 mm Hg
B. Serum potassium 5.6 mEq/L
C. Hemoglobin 10.2 g/dL
D. Serum creatinine 3.8 mg/dL
Answer: B
Rationale: In stage 4 CKD, a potassium of 5.6 mEq/L indicates hyperkalemia, which can cause
life-threatening cardiac dysrhythmias and requires immediate intervention (e.g., calcium gluconate,
insulin/glucose). Hypertension (A) is common and may need management but is not immediately critical.
Anemia (C) is typical in CKD and may be treated with erythropoietin but is not emergent. Creatinine of
3.8 (D) is elevated but stable for stage 4. The hyperkalemia poses the highest risk.
4. A patient with a history of heart failure with reduced ejection fraction (HFrEF) is admitted with
acute decompensation. The nurse administers furosemide 80 mg intravenously. One hour later, the
patient's urine output is 50 mL. Which action should the nurse take first?
A. Administer a second dose of furosemide as prescribed.
B. Assess the patient for signs of fluid overload and check renal function.
C. Increase the intravenous fluid rate to promote urine output.
D. Notify the provider of the inadequate response and request a change to a different diuretic.
Answer: B
Rationale: After IV furosemide, a urine output of 50 mL in one hour is low (expected >100 mL). The
nurse should first assess the patient (lung sounds, edema, weight) and check renal function (BUN,
creatinine) to determine if the patient is volume depleted or has renal impairment. Administering
another dose (A) without assessment could cause harm if the patient is hypovolemic. Increasing IV fluids
(C) could worsen heart failure. Notifying the provider (D) is important but assessment should come first.
5. A nurse is providing discharge teaching to a patient who has undergone a laparoscopic
cholecystectomy. Which statement by the patient indicates a need for further teaching?
A. I should avoid heavy lifting for about a week.
B. I can expect some shoulder pain due to the gas used during surgery.
C. I will need to follow a low-fat diet for several weeks.
D. I should report any clay-colored stools to my doctor.
Answer: A
Rationale: After laparoscopic cholecystectomy, patients are typically advised to avoid heavy lifting for
2-4 weeks, not just one week, to prevent hernia formation or wound dehiscence. Shoulder pain (B) from
carbon dioxide irritation is common. A low-fat diet (C) is recommended postoperatively to reduce
digestive discomfort. Clay-colored stools (D) may indicate bile duct obstruction and should be reported.
Therefore, the patient's statement about lifting for only a week is incorrect and requires further teaching.
Page 2
,6. A patient with a diagnosis of schizophrenia is prescribed clozapine. The nurse reviews the
patient's laboratory results: white blood cell count (WBC) 3,200/mm³, absolute neutrophil count
(ANC) 1,200/mm³. Which action should the nurse take?
A. Administer the clozapine as ordered and monitor the patient for side effects.
B. Hold the clozapine and notify the healthcare provider immediately.
C. Administer clozapine with a dose of filgrastim.
D. Request a repeat complete blood count in 24 hours.
Answer: B
Rationale: Clozapine can cause agranulocytosis; the ANC must be monitored. An ANC of 1,200/mm³ is
below the threshold for continuing therapy (typically >1,500 for continuation). The drug should be held
and the provider notified. Administering clozapine (A) could worsen neutropenia. Filgrastim (C) is not a
standard co-administration. Repeating CBC (D) delays necessary intervention. The priority is to stop the
drug and prevent severe neutropenia.
7. A nurse is assessing a patient who returns from a cardiac catheterization via the right femoral
artery. The nurse notes a large hematoma at the insertion site and the right foot is cool and pale
with a capillary refill of 5 seconds. Which action should the nurse perform first?
A. Apply a warm compress to the right foot.
B. Elevate the right leg on pillows.
C. Apply manual pressure to the femoral access site.
D. Notify the healthcare provider immediately.
Answer: C
Rationale: The findings indicate possible retroperitoneal bleeding or arterial occlusion. The priority is to
apply manual pressure to the femoral site to achieve hemostasis and improve perfusion. A warm
compress (A) does not address the bleeding. Elevation (B) is contraindicated as it may reduce arterial
flow further. Notifying the provider (D) is important but should be done while applying pressure.
Immediate action to control bleeding is essential.
8. A nurse is caring for a patient with a diagnosis of pulmonary embolism who is receiving a
heparin infusion. The aPTT result is 98 seconds (normal 25-35 seconds). The patient has no signs of
bleeding. What should the nurse do?
A. Increase the heparin infusion rate by 100 units/hour.
B. Decrease the heparin infusion rate by 100 units/hour.
C. Stop the heparin infusion and administer protamine sulfate.
D. Continue the heparin infusion at the current rate.
Answer: D
Rationale: For pulmonary embolism, the therapeutic aPTT range is typically 1.5-2.5 times the control
(about 60-80 seconds if control is 30, or up to 100 seconds depending on the facility). An aPTT of 98
seconds is within or slightly above therapeutic range but not critically high. Without bleeding, the
infusion should be continued at the current rate. Increasing (A) could cause supratherapeutic levels and
bleeding. Decreasing (B) could lead to subtherapeutic levels. Protamine (C) is for reversal of severe
bleeding, not indicated here.
Page 3
, 9. A patient with a history of opioid use disorder is admitted for a surgical procedure. The patient
is on methadone maintenance therapy (100 mg daily). Which prescription should the nurse
anticipate for postoperative pain management?
A. Continue methadone 100 mg daily and add a nonsteroidal anti-inflammatory drug (NSAID) as needed.
B. Discontinue methadone and start a patient-controlled analgesia (PCA) with morphine.
C. Reduce methadone to 50 mg daily and add hydromorphone for breakthrough pain.
D. Administer naloxone if respiratory depression occurs, and avoid all opioids.
Answer: A
Rationale: Methadone should be continued to prevent withdrawal and maintain stability. For
postoperative pain, multimodal analgesia including NSAIDs and possibly short-acting opioids is
appropriate. Discontinuing methadone (B) would precipitate withdrawal. Reducing methadone (C) is not
necessary and could cause withdrawal. While naloxone (D) is available for overdose, avoiding all
opioids is not realistic for significant surgical pain. Therefore, continuing methadone and adding
NSAIDs is the best approach.
10. A nurse is evaluating the effectiveness of a patient's pain management after surgery. The
patient rates pain as 4 on a 0-10 scale, but is grimacing and holding the incisional area. Which
action should the nurse take?
A. Document the pain score and continue the current plan.
B. Administer additional analgesic as prescribed.
C. Reassess the patient in 30 minutes.
D. Ask the patient why they are grimacing if the pain is only 4.
Answer: B
Rationale: The discrepancy between the verbal pain score and behavioral signs suggests the patient may
be underreporting pain or that the pain is affecting function. The nurse should administer additional
analgesic if prescribed, as the goal is to relieve pain and improve function. Documenting and continuing
(A) ignores the nonverbal cues. Waiting 30 minutes (C) delays relief. Asking the patient (D) may be
confrontational and not therapeutic. The priority is to address the apparent pain.
11. A patient with a history of chronic kidney disease (stage 4) is admitted with hyperkalemia
(serum potassium 6.8 mEq/L) and ECG changes showing peaked T waves. The nurse reviews the
electronic health record and notes the patient is prescribed several medications. Which medication
order should the nurse question as most likely contributing to the hyperkalemia?
A. Spironolactone 25 mg orally daily
B. Furosemide 40 mg intravenously every 12 hours
C. Sodium polystyrene sulfonate 15 g orally every 6 hours
D. Calcium gluconate 10% 10 mL intravenously over 3 minutes
Answer: A
Rationale: Spironolactone is a potassium-sparing diuretic that can exacerbate hyperkalemia, especially
in patients with renal impairment. Furosemide is a loop diuretic that promotes potassium excretion.
Sodium polystyrene sulfonate and calcium gluconate are treatments for hyperkalemia, not causes.
Page 4
