HESI RN EVALUATION EXAM 2026 QUESTIONS AND
SOLUTIONS SCORED A+
✔✔An older client who had abdominal surgery 3 days earlier was given a barbiturate for
sleep and is now requesting to go to the bathroom. What is the priority nursing action for
this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ✔✔A
Rationale: Barbiturates cause central nervous system (CNS) depression, and
individuals taking these medications are at greater risk for falls. The nurse should assist
the client to the bathroom. A bedpan is not necessary as long as safety is ensured.
Whether the client needs to void or have a bowel movement, option C is irrelevant in
terms of meeting this client's safety needs. There is no indication that this client cannot
voice her or his needs, so assessment of the bladder is not needed.
✔✔The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ✔✔D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is a
problem that may develop from having an indwelling catheter. Option B may or may not
be true for the client. Option C is not affected by an indwelling catheter.
✔✔When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - ✔✔C
,Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all
areas that could harbor bacteria. The child's cognitive development may not be at the
level at which option A would be effective. Perineal care needs to be provided daily
regardless of the client's age. Option D is not indicated and may be perceived as
intrusive.
✔✔A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - ✔✔B
Rationale: Caring for a close friend can violate boundaries for nurses and should be
avoided when possible (B). If the assignment is unavoidable (there are no other nurses
to care for the client) then C, A, and D should be addressed.
✔✔The nurse selects the best site for insertion of an IV catheter in the client's right arm.
Which documentation should the nurse use to identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - ✔✔B
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of
the vein that is accessed, which should be included in the documentation. The basilic
vein of the arm is used for IV access, not the brachial vein, which is too deep to be
accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible,
they are fragile and using them would be painful, so they are not recommended for IV
access. Option D is not specific enough for documenting the location of the IV access.
✔✔The nurse transcribes the postoperative prescriptions for a client who returns to the
unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
, D.
Contact the health care provider to renew the prescription for the medication. - ✔✔D
Rationale: Medications prescribed preoperatively must be renewed postoperatively, so
the nurse should contact the health care provider if the antihypertensive medication is
not included in the postoperative prescriptions. The pharmacist does not prescribe
medications or renew prescriptions. The nurse must have a current prescription before
administering any medications.
✔✔When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes
that this is the first time the client has voided in 4 hours. Which action should the nurse
take next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention. - ✔✔A
Rationale: The amount and appearance of the client's urine output is within normal
limits, so the nurse should record the output, but no additional action is needed.
✔✔The client states to the nurse, "This medication makes my mouth so dry." What are
the nurse's suggestions to quench the client's thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
E.
Keep a few pieces of hard candy with you to suck on. - ✔✔B, C, E
Rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in
them that draws fluid into the GI system. Citrus infused water quenches thirst, as does
consuming frozen liquids. Hard candy can produce moisture in the mouth.
✔✔The nurse notes in the client's plan of care altered sleep patterns related to nocturia.
Which nursing actions are important for the nurse to provide? (Select all that apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
, D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern. - ✔✔A, E
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the
production of urine, thus decreasing the need to void at night. Option E gives the nurse
the client's baseline sleep pattern. Option B helps prevent bladder infections. Option C
may promote sleep, but the fluid will contribute to nocturia. Option D may result in
urinary incontinence if the client is sedated and does not awaken to void.
✔✔The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the count
for a second 30-second interval, the nurse counts eight respirations. Which respiratory
rate will the nurse document?
A. 15
B. 16
C. 17
D. 28 - ✔✔B
Rationale: The most accurate respiratory rate is the second count obtained by the
nurse, which was not interrupted by coughing. Because it was counted for 30 seconds,
the rate should be doubled. Options A, C, and D are inaccurate recordings.
✔✔The nurse is preparing to administer a bolus tube feeding. What steps must the
nurse include prior to administering the feeding? (Select all that apply.)
A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
C.
Position the client in semi-Fowler's position.
D.
Irrigate the lumen after the contents are replaced.
E.
Warm the feeding to room temperature.
F.
Assess the pH of the stomach contents. - ✔✔A, B, E, F
Rationale: The client needs to be in high Fowler's position to decrease the risk of
aspiration. Irrigation of the lumen is only necessary if there is an obstruction. The
contents were replaced, so there is no suspicion of obstruction. The remaining steps are
correct.
✔✔Ten minutes after signing an operative permit for a fractured hip, an older client
states, "The aliens will be coming to get me soon!" and falls asleep. Which action
should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
SOLUTIONS SCORED A+
✔✔An older client who had abdominal surgery 3 days earlier was given a barbiturate for
sleep and is now requesting to go to the bathroom. What is the priority nursing action for
this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ✔✔A
Rationale: Barbiturates cause central nervous system (CNS) depression, and
individuals taking these medications are at greater risk for falls. The nurse should assist
the client to the bathroom. A bedpan is not necessary as long as safety is ensured.
Whether the client needs to void or have a bowel movement, option C is irrelevant in
terms of meeting this client's safety needs. There is no indication that this client cannot
voice her or his needs, so assessment of the bladder is not needed.
✔✔The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ✔✔D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is a
problem that may develop from having an indwelling catheter. Option B may or may not
be true for the client. Option C is not affected by an indwelling catheter.
✔✔When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - ✔✔C
,Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all
areas that could harbor bacteria. The child's cognitive development may not be at the
level at which option A would be effective. Perineal care needs to be provided daily
regardless of the client's age. Option D is not indicated and may be perceived as
intrusive.
✔✔A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - ✔✔B
Rationale: Caring for a close friend can violate boundaries for nurses and should be
avoided when possible (B). If the assignment is unavoidable (there are no other nurses
to care for the client) then C, A, and D should be addressed.
✔✔The nurse selects the best site for insertion of an IV catheter in the client's right arm.
Which documentation should the nurse use to identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - ✔✔B
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of
the vein that is accessed, which should be included in the documentation. The basilic
vein of the arm is used for IV access, not the brachial vein, which is too deep to be
accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible,
they are fragile and using them would be painful, so they are not recommended for IV
access. Option D is not specific enough for documenting the location of the IV access.
✔✔The nurse transcribes the postoperative prescriptions for a client who returns to the
unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
, D.
Contact the health care provider to renew the prescription for the medication. - ✔✔D
Rationale: Medications prescribed preoperatively must be renewed postoperatively, so
the nurse should contact the health care provider if the antihypertensive medication is
not included in the postoperative prescriptions. The pharmacist does not prescribe
medications or renew prescriptions. The nurse must have a current prescription before
administering any medications.
✔✔When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes
that this is the first time the client has voided in 4 hours. Which action should the nurse
take next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention. - ✔✔A
Rationale: The amount and appearance of the client's urine output is within normal
limits, so the nurse should record the output, but no additional action is needed.
✔✔The client states to the nurse, "This medication makes my mouth so dry." What are
the nurse's suggestions to quench the client's thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
E.
Keep a few pieces of hard candy with you to suck on. - ✔✔B, C, E
Rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in
them that draws fluid into the GI system. Citrus infused water quenches thirst, as does
consuming frozen liquids. Hard candy can produce moisture in the mouth.
✔✔The nurse notes in the client's plan of care altered sleep patterns related to nocturia.
Which nursing actions are important for the nurse to provide? (Select all that apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
, D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern. - ✔✔A, E
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the
production of urine, thus decreasing the need to void at night. Option E gives the nurse
the client's baseline sleep pattern. Option B helps prevent bladder infections. Option C
may promote sleep, but the fluid will contribute to nocturia. Option D may result in
urinary incontinence if the client is sedated and does not awaken to void.
✔✔The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the count
for a second 30-second interval, the nurse counts eight respirations. Which respiratory
rate will the nurse document?
A. 15
B. 16
C. 17
D. 28 - ✔✔B
Rationale: The most accurate respiratory rate is the second count obtained by the
nurse, which was not interrupted by coughing. Because it was counted for 30 seconds,
the rate should be doubled. Options A, C, and D are inaccurate recordings.
✔✔The nurse is preparing to administer a bolus tube feeding. What steps must the
nurse include prior to administering the feeding? (Select all that apply.)
A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
C.
Position the client in semi-Fowler's position.
D.
Irrigate the lumen after the contents are replaced.
E.
Warm the feeding to room temperature.
F.
Assess the pH of the stomach contents. - ✔✔A, B, E, F
Rationale: The client needs to be in high Fowler's position to decrease the risk of
aspiration. Irrigation of the lumen is only necessary if there is an obstruction. The
contents were replaced, so there is no suspicion of obstruction. The remaining steps are
correct.
✔✔Ten minutes after signing an operative permit for a fractured hip, an older client
states, "The aliens will be coming to get me soon!" and falls asleep. Which action
should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
