HESI RN FUNDAMENTALS EXIT EXAM LATEST
2025-2026 ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
The mental health nurse plans to discuss a client's depression with the health care provider in the
emergency department. There are two clients sitting across from the emergency department desk.
Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. D
Rationale: The best nursing action is to discuss the client another time. Confidentiality must be
observed at all times, so the nurse should not discuss the client when the conversation can be
overheard by others. Details of the client can be identified when referring to the client by gender
or age, even when not using the client's name.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports, "I am still unable to sleep, despite following the same
routine every night." Which action should the nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. D
Rationale: The nurse should first evaluate whether the client has been adhering to the original
instructions. A verbal report of the client's routine will provide more specific information than
the client's written diary. The nurse can then determine which changes need to be made. The
routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.
A client is laughing at a television program when the evening nurse enters the room. The client
states, "My foot is hurting. I would like a pain pill." How should the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control. A
1|Page
,Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his
pain helps the nurse determine which pain medication should be administered and also provides
a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be
delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be
used as an adjunct to pain medication, not instead of medication.
Which action is most important for the nurse to include in the plan of care for a client at high risk
for the development of postoperative thrombus formation?
A.
Instruct in the use of the incentive spirometer.
B.
Elevate the head of the bed during all meals.
C.
Use aseptic technique to change the dressing.
D.
Encourage frequent ambulation in the hallway. D
Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so
the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in
the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option
B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A.
Clamp the nasogastric tube.
B.
Confirm placement of the tube.
C.
Use a syringe to instill the medications.
D.
Turn off the intermittent suction device. D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube in
the stomach before instilling the medications. To prevent immediate removal of the instilled
medications and allow absorption, the tube should be clamped for a period of time before
reconnecting the suction.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice
about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse
to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
B.
"Apple juice is the most useful in acidifying the urine."
C.
"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics." C
2|Page
,Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of
Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to
be as effective as cranberry juice in preventing UTIs.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after getting
home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked questions about
medications.
B.
Advise the client to obtain a current edition of a drug reference book from a local bookstore or
library.
C.
Reassure the client that information about the medication is included in the written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any questions arise. D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse
or health care provider if any questions arise. Options A, B, and C may all include useful
information, but these sources of information cannot evaluate the nature of the client's questions
and the follow-up needed.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery
devise will the nurse select to prepare the medication?
A.
30 mL medication cup
B.
10 mL medication spoon
C.
3 mL needleless syringe
D.
5 mL medicine dropper C
Rationale: Accuracy is most important when delivering small amounts of medication to a child.
The most accurate dispensing devise is the 3 mL needleless syringe that is marked off in
increments of tenths.
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation
will cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers. D
Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to
neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these
clients. The remaining options pose a low risk for infection.
3|Page
, The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and
alert. Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
Assist the client in extending the neck back so the tube may enter the larynx. A, D
Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Placement of
an NG tube can be uncomfortable and can induce gagging. The tube should be measured from
the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The
neck should only be extended back prior to the tube passing the pharynx and then the client
should be instructed to position the neck forward (E).
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3
days. She states, "I have been told that it is harmful to bathe during my period." Which action
should the nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area.
C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with the client. D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I
know your children want to come over and say goodbye before we call the funeral home. Just let
me know when you are ready for me to prepare the body." What steps will the nurse include in
the postmortem care? (Select all that apply.)
A.
Remove the existing Foley catheter.
B.
Wash the genitalia only.
C.
Close the client's eyes.
D.
Remove soiled padding under the client.
E.
Place a dressing over the abdominal scar. A, C, D
4|Page
2025-2026 ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
The mental health nurse plans to discuss a client's depression with the health care provider in the
emergency department. There are two clients sitting across from the emergency department desk.
Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. D
Rationale: The best nursing action is to discuss the client another time. Confidentiality must be
observed at all times, so the nurse should not discuss the client when the conversation can be
overheard by others. Details of the client can be identified when referring to the client by gender
or age, even when not using the client's name.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports, "I am still unable to sleep, despite following the same
routine every night." Which action should the nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. D
Rationale: The nurse should first evaluate whether the client has been adhering to the original
instructions. A verbal report of the client's routine will provide more specific information than
the client's written diary. The nurse can then determine which changes need to be made. The
routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.
A client is laughing at a television program when the evening nurse enters the room. The client
states, "My foot is hurting. I would like a pain pill." How should the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control. A
1|Page
,Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his
pain helps the nurse determine which pain medication should be administered and also provides
a baseline for evaluating the effectiveness of the medication. Medicating for pain should not be
delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be
used as an adjunct to pain medication, not instead of medication.
Which action is most important for the nurse to include in the plan of care for a client at high risk
for the development of postoperative thrombus formation?
A.
Instruct in the use of the incentive spirometer.
B.
Elevate the head of the bed during all meals.
C.
Use aseptic technique to change the dressing.
D.
Encourage frequent ambulation in the hallway. D
Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so
the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in
the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option
B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A.
Clamp the nasogastric tube.
B.
Confirm placement of the tube.
C.
Use a syringe to instill the medications.
D.
Turn off the intermittent suction device. D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube in
the stomach before instilling the medications. To prevent immediate removal of the instilled
medications and allow absorption, the tube should be clamped for a period of time before
reconnecting the suction.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice
about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse
to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
B.
"Apple juice is the most useful in acidifying the urine."
C.
"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics." C
2|Page
,Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of
Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to
be as effective as cranberry juice in preventing UTIs.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after getting
home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked questions about
medications.
B.
Advise the client to obtain a current edition of a drug reference book from a local bookstore or
library.
C.
Reassure the client that information about the medication is included in the written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any questions arise. D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse
or health care provider if any questions arise. Options A, B, and C may all include useful
information, but these sources of information cannot evaluate the nature of the client's questions
and the follow-up needed.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery
devise will the nurse select to prepare the medication?
A.
30 mL medication cup
B.
10 mL medication spoon
C.
3 mL needleless syringe
D.
5 mL medicine dropper C
Rationale: Accuracy is most important when delivering small amounts of medication to a child.
The most accurate dispensing devise is the 3 mL needleless syringe that is marked off in
increments of tenths.
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation
will cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers. D
Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to
neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these
clients. The remaining options pose a low risk for infection.
3|Page
, The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and
alert. Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
Assist the client in extending the neck back so the tube may enter the larynx. A, D
Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Placement of
an NG tube can be uncomfortable and can induce gagging. The tube should be measured from
the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The
neck should only be extended back prior to the tube passing the pharynx and then the client
should be instructed to position the neck forward (E).
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3
days. She states, "I have been told that it is harmful to bathe during my period." Which action
should the nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area.
C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with the client. D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I
know your children want to come over and say goodbye before we call the funeral home. Just let
me know when you are ready for me to prepare the body." What steps will the nurse include in
the postmortem care? (Select all that apply.)
A.
Remove the existing Foley catheter.
B.
Wash the genitalia only.
C.
Close the client's eyes.
D.
Remove soiled padding under the client.
E.
Place a dressing over the abdominal scar. A, C, D
4|Page
