HESI EXIT NGN, HESI RN Exit Exam (2025) comprehensive questions and verified answers ( detailed & elaborated) ACTUAL EXAM 2025 TEST!!

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?

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?

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?

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?

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

-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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

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?

take metformin for type 2 diabetes

The nurse should withhold which medication if the client's serum potassium level is 6.2 mEq/?

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?

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?

-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

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?

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

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?

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?

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?

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

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?

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?

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?

Suggest the nurse use 20g needle

A nurse working on an Endocrine Unit should see which client first?

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?

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?

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?

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?

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?

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?

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?

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?

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.

Brush the child's teeth everyday and ensure the child receives regular dental follow up.

A pt who is admitted with complications related to hypopituitarism is diaphoretic and hypotensive. Which assessment finding warrants immediate intervention by the nurse?

Lethargy

The nurse identifies an electrolyte imbalance, a weight gain of 4.4lbs in 24 hours and an elevated central venous pressure for a pt with full thickness burns. Which intervention should the nurse implement?

Auscultate for irregular heart rate.

A nurse who is working in the emergency department triage area is presented with four clients at the same time. The client presenting with which symptoms require the most immediate intervention by the nurse?

Chest discomfort one hour after consuming a large spicy meal.

Which self care measure is most important to include in the plan of care of a pt recently diagnosed with type 2 diabetes mellitus?

blood glucose monitoring.

In assessing a pt with type 1 diabetes mellitus, the nurse notes that the client's respirations have changed from 16 breaths/min with a normal depth to 32 breaths/min and deep. And the pt has become lethargic. Which assessment data should the nurse obtain next?

blood glucose

An adolescent who was diagnosed with diabetes mellitus Type 1 at the age of 9 is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of ketoacidosis?

had a cold and ear infection for the past two days.

The nurse assesses a pt who had bilateral total knee replacements four hours ago. The nurse notes that the dressing on the right knee is saturated with serosanguineous drainage. What action should the nurse implement?

Determine if the wound drainage device is functioning correctly.

A pt with chronic kidney disease has an arteriovenous (AV) fistula in the left forearm. Which observation by the nurse indicates that the fistula is patient?

Auscultation of a thrill on the left forearm

A client with urge incontinence was treated with onabotulinumtoxinA injections and is now experiencing urinary retention. Which action should the nurse include in the client's plan of care?

Remind the pt to practice pelvic floor exercises regularly.

A pt is admitted with a dx of urolithiasis. Which finding is most important for the nurse to report to the healthcare provider?

Hematuria that is beginning to turn pink

The nurse is evaluating the chest drainage system of a patient with a chest tube inserted to treat a left hemothorax. Which finding requires intervention by the nurse?

cont. bubbling in the water seal chamber

The nurse is caring for a pt who has chronic obstructive pulmonary disease and chest pain related to a recent fall. What nursing intervention requires the greatest caution when caring for a pt with COPD?

administering narcotics for pain relief

The nurse instructs a pt in use of an incentive spirometer. The client performs a return demonstration as seen in the video. Which action should the nurse take in response to the return demonstration?

Remind the pt to cough using the spirometer

The healthcare provider prescribes a sepsis protocol for a pt with organ failure caused by a ruptured appendix. Which intervention is most important for the nurse to include in the plan of care?

Maintain strict intake and output

A pt diagnosed with calcium kidney stones has a history of gout. A new prescription for aluminum hydroxide is scheduled to begin at 0730. Which client medication should the nurse bring to the healthcare provider's attention?

Allopurinol

An adult client is admitted to the ED after falling from a ladder. While waiting to have a CT scan, the client requests something for a severe headache. When the nurse offers a prescribed dose of acetaminophen, the pt asks for something stronger. Which intervention should the nurse implement?

Explain the reason for using only non-narcotics

The nurse is providing care for a pt with severe peripheral arterial disease. The pt reports a history of rest ischemia, with leg pain that occurs during the night. Which action should the nurse take in response to this finding?

Offer cold packs when pain occurs

When taking a health history, which information collected by the nurse correlates most directly to a diagnosis of chronic peripheral arterial insufficiency?

History of intermittent claudication

the nurse assesses a pt being treated for Herpes Zoster (Shingles). Which assessments should the nurse include when evaluating the effectiveness of treatment? SATA

Functional ability

skin integrity

pain scale

A young male client is admitted to rehabilitation following a right above the knee amputation for a severe traumatic injury. He is in the commons room and anxiously calls out to the nurse, stating that his right foot is aching. The nurse offers reassurance and support. Which additional intervention is most important for the nurse to implement?

encourage discussion of feelings about the loss of his limb

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Test the fluid on the dressing for glucose

An older client with a long history of coronary artery disease, hypertension, and heart failure arrives in the ED with respiratory distress. The healthcare provider prescribes furosemide IV. Which therapeutic response to furosemide should the nurse expect with the acute HR?

Reduced preload.

A young adult visits the clinic reporting symptoms associated with gastritis. Which information in the pt history is most important for the nurse to address in the teaching?

consume 10 or more drinks of alcohol every weekend.

The nurse completed the admission assessment of a 3-year-old who is admitted with bacterial meningitis and hydrocephalus. Which assesses evidence that the child is experiencing increased intracranial pressure.

sluggish and unequal pupillary responses

A teenager presents to the emergency dept with palpitations after vaping at a party. The pt is anxious, fearful, and hyperventilating. The nurse anticipates the developing acid base imbalance?

respiratory alkalosis

Which intervention should the nurse include in the plan of care for a child with tetanus?

minimize the amount of stimuli in the room

The nurse is caring for a 24 month old toddler who has sensory sensitivity, difficulty engaging in social interactions, and has not yet spoken two word phrases. Which assessment should the nurse administer?

The modified checklist for Autism

A client fell in the bathroom when left unattended by the UAP. Which information should the nurse include in the pt health record?

The pt fell sustaining a fracture to the left hip

the nurse is caring for a group of clients with the help of a PN. Which nursing actions should the nurse assign to the PN?

Administer a dose of insulin per sliding scale with type 2 diabetes mellitus

Perform daily surgical dressing change for a pt who had an abdominal hysterectomy

Obtain postoperative vital signs for a pt one day post op.

A UAP is assigned to ambulate a pt with influenza who has droplet precautions implemented. The UAP requests a change in assignment, stating the reason of having not been fitted yet for a N95 respirator mask. Which action should the nurse take?

Instruct the UAP that a standard face mask is sufficient for the provision of care for the assigned client.

When providing patient care, the nurse sees a problem and develops a related clinical question. Next, the nurse intends to gather evidence so that the decision making process in response to the problem and clinical question is evidence- based. When gathering evidence, which consideration is most important?

Relevance to the situation

The nurse is auscultating a pt lung sounds. Which description should the nurse use to document this sound?

High pitched or fine crackles

When admitting a pt with a dx of transient ischemic attack (TIA), which intervention is most important for the nurse to include in the client's plan of care?

Initiate neurological monitoring every 2 hours

The nurse is developing a plan of care for a pt who reports tingling of the feet and who is newly diagnosed with peripheral vascular disease. Which outcome should the nurse include in the plan of care for this client?

The pt blood pressure readings will be less than 160/90

Prior to surgery, written consent must be obtained. Which is the nurse's legal responsibility with regard to obtaining written consent?

Determine that the surgical consent form has been signed and is included in the pt record

A client presents to the emergency dept with muscle aches, headache, fever, and describes a recent loss of taste and smell. The nurse obtains a swab for COVID -19 testing. Which action is most important for the nurse to take?

place the nasal swab specimen for COVID 19 directly in a biohazard bag.

What might the nurse suggest to a pt with fibrocystic breasts in an attempt to help relieve her symptoms?

increase high calcium foods in diet

The nurse is assessing a pt who reported falling 2 days ago and has a history of gouty arthritis that is controlled with allopurinol. The pt states the left knee is swollen and extremely painful to the touch. Which instructions should the nurse include in the discharge teaching?

decrease consumption of red meat and most seafood.

The nurse is teaching a group of women about osteoporosis and exercise. The nurse should emphasize the need for which type of regular activity?

Weight bearing exercise

A male client with cirrhosis has jaundice and pruritus. He tells the nurse that he has been soaking in hot baths at night with no relief of his discomfort. Which action should the nurse take?

Encourage the pt to use cooler water and apply calamine lotion after soaking.

A pt with rheumatoid arthritis starts a new prescription for subcutaneously once weekly. The nurse emphasizes the importance of reporting which problem to the healthcare provider?

Joint stiffness

An adult female tells the nurse that though she is afraid that her abusive boyfriend might one day kill her, she keeps hoping that he will change. Which action should the nurse take first?

Explore the pt readiness to discuss the situation

A male client approaches the nurse with an angry expression on his face and raises his voice, saying, "My roommate is the most selfish, self-centered, angry person I have ever met If he loses his temper one more time with me, I am going to punch him." The nurse recognizes that the pt is using which defense mechanism?

Projection

A young adult male who is being seen at the employee health care clinic for an annual assessment tells the nurse that his mother was diagnosed with schizophrenia when she was his age and that life with a schizophrenic mother was difficult indeed. Which response is best for the nurse to provide?

Ask the pt if he is worried about becoming schizophrenic at the same age his mother was dx.

On admission to the Emergency Department, a female client who was diagnosed with bipolar disorder 3 years ago reports that this morning she took a handful of medications and left a suicide note for her family. Which information is most important for the nurse to obtain?

When the pt last took drugs for bipolar disorder

The nurse is providing care for a pt with schizophrenia who receives haloperidol decanoate 75 mg intramuscularly every 4 weeks. The pt begins developing puckering and smacking of the lips and facial grimacing. Which intervention should the nurse implement?

Complete abnormal involuntary movement scale

A pt with postpartum depression, who is admitted to the behavioral health unit refuses to leave her room or eat meals. In addition to maintaining physical safety, which short term goal should the nurse include in the plan of care?

Attends one group activity per day

The psychiatric nurse is caring for pts on an adolescent unit. Which client requires the nurse's immediate attention

An 18 year old pt with antisocial behavior who is being yelled at by other pts.

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Practice using muscle relaxation techniques

A preschool aged boy is admitted to the pediatric unit following successful resuscitation from a near drowning incident. While providing care to the child, the nurse begins with the brother who rescued the child from the swimming pool and initiated resuscitation. The nurse notices the older boy becomes withdrawn when asked about what happened. Which action should the nurse take?

Ask the older brother how he felt during the incident.

The nurse is completing the admission assessment of a 3-year old who is admitted with bacterial meningitis and hydrocephalus. Which assessment finding is evidence that the child is experiencing increased intracranial pressure (ICP)?

A. Tachycardia and tachypnea

B. Sluggish and unequal pupillary responses

C. Increased head circumference and bulging fontanels

D. Blood pressure fluctuations and syncope

B. Sluggish and unequal pupillary responses

A client with acute pancreatitis is admitted with severe, piercing abdominal pain and an elevated serum amylase. Which additional information is the client most likely to report to the nurse?

A. Abdominal pain decreases when lying supine

B. Pain lasts an hour and leaves the abdomen tender

C. Right upper quadrant pain refers to right scapula

D. Drinks alcohol until intoxicated at least twice weekly.

A. Abdominal pain decreases when lying supine

A child newly diagnosed with sickle cell anemia (SCA) is being discharged from the hospital. Which information is most important for the nurse to provide the parents prior to discharge?

A. Instructions about how much fluid the child should drink daily.

B. Signs of addiction to opioid pain medications

C. Information about non-pharmaceutical pain relief measures

D. Referral for social services for the child and family

A. Instructions about how much fluid the child should drink daily

To auscultate for a carotid bruit, the nurse places the stethoscope at what location. (Select the location on the image with a red dot).

I placed the red dot on the base of the neck on the right side

After receiving report on an inpatient acute care unit, which client should the nurse assess first?

A. The client with an obstruction of the large intestine who is experiencing abdominal distention

B. The client who had surgery yesterday and is experiencing a paralytic ileus with absent bowel sounds

C. The client with a small bowel obstruction who has a nasogastric tube that is draining greenish fluid

D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

D. The client with a bowel obstruction due to a volvulus who is experiencing abdominal rigidity

A teenager presents to the emergency department with palpitations after vaping at a party. The client is anxious, fearful, and hyperventilating. The nurse anticipates the client developing which acid base imbalance?

A. Respiratory acidosis

B. Metabolic alkalosis

C. Metabolic acidosis

D. Respiratory alkalosis

D. Respiratory alkalosis