HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2026-2027 ACTUAL EXAM 100
QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child
is often awake until midnight playing and is then very difficult to awaken in the
morning for school. Which assessment data should the nurse obtain in response
to the mother's concern?
A.
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
D
Rationale: School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that may not be
conducive to the establishment of bedtime rituals that promote sleep. Option A
often causes daytime fatigue rather than resistance to going to sleep. Option B is
unlikely to provide useful data. The nurse cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has the
highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
,C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A reverses
the hypovolemia that initially accompanies burn trauma but is not related to
decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of
infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even though the venous access site is
healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
B
Rationale: The nurse should first check the tubing and height of the bag on the IV
pole, which are common factors that may slow the rate. Gravity infusion rates are
influenced by the height of the bag, tubing clamp closure or kinks, needle size or
position, fluid viscosity, client blood pressure (crying in the pediatric client), and
infiltration. Venospasm can slow the rate and often responds to warmth over the
vessel, but the nurse should first adjust the IV pole height. The nurse may need to
adjust the stabilizing tape on a positional needle or flush the venous access with
normal saline, but less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in
,this instruction?
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.
A
Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.
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.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother
states, "I think my 4-month-old baby is choking!" What steps will the nurse take?
(Select all that apply.)
A.
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.
B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
LATEST 2026-2027 ACTUAL EXAM 100
QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child
is often awake until midnight playing and is then very difficult to awaken in the
morning for school. Which assessment data should the nurse obtain in response
to the mother's concern?
A.
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
D
Rationale: School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that may not be
conducive to the establishment of bedtime rituals that promote sleep. Option A
often causes daytime fatigue rather than resistance to going to sleep. Option B is
unlikely to provide useful data. The nurse cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness
(second-degree) and full-thickness (third-degree) burns. What action has the
highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
,C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A reverses
the hypovolemia that initially accompanies burn trauma but is not related to
decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of
infection. Option B is a proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that
the peripheral IV rate by gravity has slowed, even though the venous access site is
healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
B
Rationale: The nurse should first check the tubing and height of the bag on the IV
pole, which are common factors that may slow the rate. Gravity infusion rates are
influenced by the height of the bag, tubing clamp closure or kinks, needle size or
position, fluid viscosity, client blood pressure (crying in the pediatric client), and
infiltration. Venospasm can slow the rate and often responds to warmth over the
vessel, but the nurse should first adjust the IV pole height. The nurse may need to
adjust the stabilizing tape on a positional needle or flush the venous access with
normal saline, but less invasive actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in
,this instruction?
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.
A
Rationale: Performing range-of-motion exercises is beneficial in reducing
contractures around joints. Options B, C, and D are all potentially harmful
practices that place the immobile client at risk of complications.
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.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother
states, "I think my 4-month-old baby is choking!" What steps will the nurse take?
(Select all that apply.)
A.
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.
B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
