NUR 3535C HESI RN FUNDAMENTALS EXIT EXAM
REVIEW 2025–2026 – NURSING PRACTICE
QUESTIONS WITH ANSWERS AND RATIONALES
The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and
8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan
on drawing the test?
A.
7:00 am
B.
9:00 am
C.
12:00 noon
D.
2:00 pm
A
Rationale: The aPTT test should be drawn 1 hour before the scheduled dose.
The nurse is providing care to a client who had major abdominal surgery. Upon return from
the recovery room, the client's vital signs were at the pre-operative baseline. The client was
sleepy, but arousable, and the skin was warm and dry to the touch. At the 1 hour post
admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and
the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all
that apply.)
A.
Call the health care provider.
B.
,Elevate the head of the bed.
C.
Observe for restlessness/confusion.
D.
Administer oxygen by re-breather mask.
E.
Observe the abdominal bandage.
A, C, D, E
Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency.
The head of bed may need to be lowered or placed in Trendelenburg position to increase
circulation to the brain. The remaining selections are correct.
The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated.
Which findings support the evaluation? (Select all that apply.)
A.
The area around the insertion site is swollen.
B.
There is bruising 1 inch below the insertion site.
C.
The insertion site is cool to the touch.
D.
The client complains of a burning pain at the site.
E.
Redness is noted in the area of the insertion site.
F.
Blood is noted in the IV tubing when the IV bag is lowered.
,A, C, D, E
Rationale: Bruising is an accumulation of blood under the skin, most likely from oozing with
the insertion of the IV. When blood is noted in the IV tubing when the IV bag is lowered, that
is a sign of patency. The remaining signs are related to infiltration.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at
1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at
1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action?
A.
Contact the healthcare provider on call.
B.
Call in the off going nurse and request an explanation.
C.
Tell the client that 950 mL of fluid just accidentally infused.
D.
Auscultate the client's lungs.
D
Rationale: The client may show signs of fluid overload, such as crackles. Other respiratory
signs are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first
and then proceed with notifying the charge nurse and the health care provider.
The health care provider has changed a client's prescription from the PO to the IV route of
administration. The nurse should anticipate which change in the pharmacokinetic
properties of the medication?
A.
The client will experience increased tolerance to the drug's effects and may need a higher
dose.
, B.
The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
C.
The medication will be more highly protein-bound, increasing the duration of action.
D.
The therapeutic index will be increased, placing the client at greater risk for toxicity.
B
Rationale: Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in a more
immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not
affected by the change in route from PO to IV. In addition, an increased therapeutic index
reduces the risk of drug toxicity.
Which steps should the nurse take when administering ear drops to an adult client? (Select
all that apply.)
A.
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back.
A, B
REVIEW 2025–2026 – NURSING PRACTICE
QUESTIONS WITH ANSWERS AND RATIONALES
The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and
8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan
on drawing the test?
A.
7:00 am
B.
9:00 am
C.
12:00 noon
D.
2:00 pm
A
Rationale: The aPTT test should be drawn 1 hour before the scheduled dose.
The nurse is providing care to a client who had major abdominal surgery. Upon return from
the recovery room, the client's vital signs were at the pre-operative baseline. The client was
sleepy, but arousable, and the skin was warm and dry to the touch. At the 1 hour post
admission assessment the nurse notes: heart rate 120 and thready, B/P 70/40 mm Hg, and
the skin is cool and clammy to the touch. What are the priority nursing actions? (Select all
that apply.)
A.
Call the health care provider.
B.
,Elevate the head of the bed.
C.
Observe for restlessness/confusion.
D.
Administer oxygen by re-breather mask.
E.
Observe the abdominal bandage.
A, C, D, E
Rationale: The client's is showing signs of hemorrhagic shock. This is a medical emergency.
The head of bed may need to be lowered or placed in Trendelenburg position to increase
circulation to the brain. The remaining selections are correct.
The nurse evaluates the insertion site of an IV catheter and suspects the IV is infiltrated.
Which findings support the evaluation? (Select all that apply.)
A.
The area around the insertion site is swollen.
B.
There is bruising 1 inch below the insertion site.
C.
The insertion site is cool to the touch.
D.
The client complains of a burning pain at the site.
E.
Redness is noted in the area of the insertion site.
F.
Blood is noted in the IV tubing when the IV bag is lowered.
,A, C, D, E
Rationale: Bruising is an accumulation of blood under the skin, most likely from oozing with
the insertion of the IV. When blood is noted in the IV tubing when the IV bag is lowered, that
is a sign of patency. The remaining signs are related to infiltration.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR was hung at
1845. The prescribed infusion rate is 75 mL/hr. The oncoming nurse assesses the client at
1915 and notes there is less than 50 mL left in the IV bag. What is the nurse's next action?
A.
Contact the healthcare provider on call.
B.
Call in the off going nurse and request an explanation.
C.
Tell the client that 950 mL of fluid just accidentally infused.
D.
Auscultate the client's lungs.
D
Rationale: The client may show signs of fluid overload, such as crackles. Other respiratory
signs are dyspnea and increased rate. Assess the client's reaction to the fluid bolus first
and then proceed with notifying the charge nurse and the health care provider.
The health care provider has changed a client's prescription from the PO to the IV route of
administration. The nurse should anticipate which change in the pharmacokinetic
properties of the medication?
A.
The client will experience increased tolerance to the drug's effects and may need a higher
dose.
, B.
The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
C.
The medication will be more highly protein-bound, increasing the duration of action.
D.
The therapeutic index will be increased, placing the client at greater risk for toxicity.
B
Rationale: Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in a more
immediate effect. Drug tolerance, protein binding, and the drug's therapeutic index are not
affected by the change in route from PO to IV. In addition, an increased therapeutic index
reduces the risk of drug toxicity.
Which steps should the nurse take when administering ear drops to an adult client? (Select
all that apply.)
A.
Place the client in a side-lying position.
B.
Pull the auricle upward and outward.
C.
Hold the dropper 6 cm above the ear canal.
D.
Place a cotton ball into the inner canal.
E.
Pull the auricle down and back.
A, B
