HESI RN FUNDAMENTALS EXIT
EXAM LATEST 2024-2025
ACTUAL EXAM 100 QUESTIONS
AND CORRECT ANSWERS
WITH RATIONALES (VERIFIED
ANSWERS) | Graded A+
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive Rationales
Included
,The nurse is called to the waiting room of a pediatric B, C, D
clinic. The frantic mother states, "I think my 4-month-old Rationale: The fingers are placed at the same location on an infant as chest
baby is choking!" What steps will the nurse take? (Select compressions for CPR; however, the nurse must deliver five chest thrusts, after the
all that apply.) five back slaps. Blind sweeps are not used as this action may push the object
A. deeper into the throat. The remaining steps are correct.
Compress the chest once between the nipples with two
fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with
A. blood.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
,When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the
A. nurse a wide base of support while stabilizing the client's knees when assisting to
Place the chair parallel to the bed, with its back toward a standing position. The chair should be placed at a 45-degree angle to the bed,
the head of the bed and assist the client in moving to the with the back of the chair toward the head of the bed. Clients should never be
chair. lifted under the axillae; this could damage nerves and strain the nurse's back. The
B. client should be instructed to use the arms of the chair and should never place his
With the nurse's feet spread apart and knees aligned with or her arms around the nurse's neck; this places undue stress on the nurse's neck
the client's knees, stand and pivot the client into the chair. and back and increases the risk for a fall.
C.
Assist the client to a standing position by gently lifting
upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around
the nurse's neck, and gently move the client to the chair.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation of this Rationale: When obtaining the blood pressure in the lower extremities, the
procedure requires the nurse to intervene with the UAP's popliteal pulse is the site for auscultation when the blood pressure cuff is applied
approach? around the thigh. The nurse should intervene with the UAP who has applied the
A. cuff on the lower leg. Option A ensures an accurate assessment, and option C
The cuff wraps around the girth of the leg. provides the best access to the artery. Systolic pressure in the popliteal artery is
B. usually 10 to 40 mm Hg higher than in the brachial artery.
The UAP auscultates the popliteal pulse with the cuff on
the lower leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood
pressure in the client's arm.
During a clinic visit, the mother of a 7-year-old reports to D
the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse should begin by
playing and is then very difficult to awaken in the morning assessing the environment of the home to determine factors that may not be
for school. Which assessment data should the nurse conducive to the establishment of bedtime rituals that promote sleep. Option A
obtain in response to the mother's concern? often causes daytime fatigue rather than resistance to going to sleep. Option B is
A. unlikely to provide useful data. The nurse cannot determine option C.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child
is experiencing
D.
Description of the family's home environment
, The nurse identifies a potential for infection in a client B
with partial-thickness (second-degree) and full-thickness Rationale: Careful handwashing technique is the single most effective intervention
(third-degree) burns. What action has the highest priority for the prevention of contamination to all clients. Option A reverses the
in decreasing the client's risk of infection? hypovolemia that initially accompanies burn trauma but is not related to
A. decreasing the proliferation of infective organisms. Options C and D are
Administration of plasma expanders recommended by various burn centers as possible ways to reduce the chance of
B. infection. Option B is a proven technique to prevent infection.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by Rationale: The nurse should first check the tubing and height of the bag on the IV
gravity has slowed, even though the venous access site is pole, which are common factors that may slow the rate. Gravity infusion rates are
healthy. What should the nurse do next? influenced by the height of the bag, tubing clamp closure or kinks, needle size or
A. position, fluid viscosity, client blood pressure (crying in the pediatric client), and
Apply a warm compress proximal to the site. infiltration. Venospasm can slow the rate and often responds to warmth over the
B. vessel, but the nurse should first adjust the IV pole height. The nurse may need to
Check for kinks in the tubing and raise the IV pole. adjust the stabilizing tape on a positional needle or flush the venous access with
C. normal saline, but less invasive actions should be implemented first.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
The nurse manager of a skilled nursing (chronic care) unit A
is instructing UAPs on ways to prevent complications of Rationale: Performing range-of-motion exercises is beneficial in reducing
immobility. Which action should be included in this contractures around joints. Options B, C, and D are all potentially harmful
instruction? practices that place the immobile client at risk of complications.
A.
Perform range-of-motion exercises to prevent
contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism
occurrence.
D.
Turn the client from side to back every shift.
The nurse administered 10 mg of diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation by
(Select all that apply.) placing the client close to the nurse's station is not necessary. The medication has
A. a sedative effect and the client should not get out of bed, even with assistance.
Place the client in the bed next to the nurse's station. The remaining selections are correct.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom
EXAM LATEST 2024-2025
ACTUAL EXAM 100 QUESTIONS
AND CORRECT ANSWERS
WITH RATIONALES (VERIFIED
ANSWERS) | Graded A+
Updated 2026 Questions and Answers
100% Verified Exam Prep and Comprehensive Rationales
Included
,The nurse is called to the waiting room of a pediatric B, C, D
clinic. The frantic mother states, "I think my 4-month-old Rationale: The fingers are placed at the same location on an infant as chest
baby is choking!" What steps will the nurse take? (Select compressions for CPR; however, the nurse must deliver five chest thrusts, after the
all that apply.) five back slaps. Blind sweeps are not used as this action may push the object
A. deeper into the throat. The remaining steps are correct.
Compress the chest once between the nipples with two
fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with
A. blood.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
,When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the
A. nurse a wide base of support while stabilizing the client's knees when assisting to
Place the chair parallel to the bed, with its back toward a standing position. The chair should be placed at a 45-degree angle to the bed,
the head of the bed and assist the client in moving to the with the back of the chair toward the head of the bed. Clients should never be
chair. lifted under the axillae; this could damage nerves and strain the nurse's back. The
B. client should be instructed to use the arms of the chair and should never place his
With the nurse's feet spread apart and knees aligned with or her arms around the nurse's neck; this places undue stress on the nurse's neck
the client's knees, stand and pivot the client into the chair. and back and increases the risk for a fall.
C.
Assist the client to a standing position by gently lifting
upward, underneath the axillae.
D.
Stand beside the client, place the client's arms around
the nurse's neck, and gently move the client to the chair.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation of this Rationale: When obtaining the blood pressure in the lower extremities, the
procedure requires the nurse to intervene with the UAP's popliteal pulse is the site for auscultation when the blood pressure cuff is applied
approach? around the thigh. The nurse should intervene with the UAP who has applied the
A. cuff on the lower leg. Option A ensures an accurate assessment, and option C
The cuff wraps around the girth of the leg. provides the best access to the artery. Systolic pressure in the popliteal artery is
B. usually 10 to 40 mm Hg higher than in the brachial artery.
The UAP auscultates the popliteal pulse with the cuff on
the lower leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood
pressure in the client's arm.
During a clinic visit, the mother of a 7-year-old reports to D
the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse should begin by
playing and is then very difficult to awaken in the morning assessing the environment of the home to determine factors that may not be
for school. Which assessment data should the nurse conducive to the establishment of bedtime rituals that promote sleep. Option A
obtain in response to the mother's concern? often causes daytime fatigue rather than resistance to going to sleep. Option B is
A. unlikely to provide useful data. The nurse cannot determine option C.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child
is experiencing
D.
Description of the family's home environment
, The nurse identifies a potential for infection in a client B
with partial-thickness (second-degree) and full-thickness Rationale: Careful handwashing technique is the single most effective intervention
(third-degree) burns. What action has the highest priority for the prevention of contamination to all clients. Option A reverses the
in decreasing the client's risk of infection? hypovolemia that initially accompanies burn trauma but is not related to
A. decreasing the proliferation of infective organisms. Options C and D are
Administration of plasma expanders recommended by various burn centers as possible ways to reduce the chance of
B. infection. Option B is a proven technique to prevent infection.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by Rationale: The nurse should first check the tubing and height of the bag on the IV
gravity has slowed, even though the venous access site is pole, which are common factors that may slow the rate. Gravity infusion rates are
healthy. What should the nurse do next? influenced by the height of the bag, tubing clamp closure or kinks, needle size or
A. position, fluid viscosity, client blood pressure (crying in the pediatric client), and
Apply a warm compress proximal to the site. infiltration. Venospasm can slow the rate and often responds to warmth over the
B. vessel, but the nurse should first adjust the IV pole height. The nurse may need to
Check for kinks in the tubing and raise the IV pole. adjust the stabilizing tape on a positional needle or flush the venous access with
C. normal saline, but less invasive actions should be implemented first.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
The nurse manager of a skilled nursing (chronic care) unit A
is instructing UAPs on ways to prevent complications of Rationale: Performing range-of-motion exercises is beneficial in reducing
immobility. Which action should be included in this contractures around joints. Options B, C, and D are all potentially harmful
instruction? practices that place the immobile client at risk of complications.
A.
Perform range-of-motion exercises to prevent
contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism
occurrence.
D.
Turn the client from side to back every shift.
The nurse administered 10 mg of diazepam to the B, C, D
preoperative client. What steps will the nurse take next? Rationale: Diazepam is a common preoperative medication. Close observation by
(Select all that apply.) placing the client close to the nurse's station is not necessary. The medication has
A. a sedative effect and the client should not get out of bed, even with assistance.
Place the client in the bed next to the nurse's station. The remaining selections are correct.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom
