Fortis HESI Exit Exams Comprehensive Nursing Study
Bundle Actual 2026/2027 with Detailed Rationales |
100% Verified | Pass Guaranteed – A+ Graded
Section 1: Management of Care (18 Questions)
Q1: A nurse is delegating tasks to unlicensed assistive personnel (UAP) on a busy
medical-surgical unit. Which task is appropriate to delegate to the UAP?
A. Administering oral medications to a stable client
B. Assessing a postoperative client's incision for signs of infection
C. Assisting a client with ambulation to the bathroom
D. Teaching a newly diagnosed diabetic client about insulin administration
Correct Answer: C
Rationale: Correct because assisting with ambulation is within the UAP's scope of
practice; medication administration, assessments, and client education require
licensed nursing judgment.
Q2: A client with a new colostomy expresses concern about odor control. Which
nursing action demonstrates client advocacy?
A. Telling the client that odor is unavoidable with a colostomy
B. Providing the client with educational resources on odor-reducing products and
pouching systems
C. Suggesting the client avoid social situations to prevent embarrassment
D. Asking the physician to prescribe a different type of ostomy
Correct Answer: B
Rationale: Correct because advocating for the client involves empowering them with
information and resources to manage their condition and maintain quality of life.
Q3: During a code blue, the charge nurse assigns the primary nurse to document the
event. Which leadership style is being demonstrated?
A. Autocratic
B. Democratic
C. Laissez-faire
D. Situational
Correct Answer: D
,Rationale: Correct because situational leadership adapts to the immediate context;
during a crisis, the charge nurse assigns roles based on the situation and team
members' capabilities.
Q4: A nurse discovers that a colleague has documented vital signs for a client
without actually assessing them. What is the nurse's first action?
A. Confront the colleague in front of the nursing team
B. Report the incident to the state board of nursing immediately
C. Discuss the concern with the colleague privately and report to the charge nurse if
the behavior continues
D. Document the observation in the client's medical record
Correct Answer: C
Rationale: Correct because the nurse should first address the colleague directly
using professional communication; if the behavior persists, it must be escalated to
protect client safety.
Q5: A client scheduled for surgery asks the nurse to witness a living will. What is the
nurse's appropriate response?
A. Agree to witness the document since the client trusts the nurse
B. Refuse and inform the client that witnesses cannot be involved in the client's care
C. Contact the surgeon to witness the document instead
D. Ask the client's family member to serve as the witness
Correct Answer: B
Rationale: Correct because legal standards require that witnesses to advance
directives be impartial and not involved in the client's direct care to avoid conflict of
interest.
Q6: Which action by the nurse demonstrates proper prioritization using Maslow's
hierarchy of needs?
A. Addressing a client's anxiety about an upcoming procedure before assisting with
toileting
B. Providing pain medication to a client reporting a headache of 8/10 before offering
emotional support
C. Teaching a client about discharge dietary restrictions before ensuring the client
can breathe comfortably
D. Arranging a family conference about end-of-life care before ensuring the client is
hydrated
Correct Answer: B
,Rationale: Correct because pain relief addresses a physiological need, which takes
priority over psychosocial needs according to Maslow's hierarchy.
Q7: A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 128/82 mmHg who is requesting a sleeping pill
B. A client with a respiratory rate of 28 breaths/min and oxygen saturation of 88% on
room air
C. A client with a scheduled wound dressing change in 30 minutes
D. A client who needs discharge teaching before leaving at noon
Correct Answer: B
Rationale: Correct because the client with tachypnea and hypoxemia has
compromised airway and breathing, which are the highest priority using the ABC
approach.
Q8: A nurse manager is implementing quality improvement on the unit. Which
activity is most appropriate for the manager to delegate to a staff nurse?
A. Analyzing unit-wide infection rate data and presenting findings to administration
B. Collecting data on the incidence of falls over the past quarter
C. Developing a new hospital-wide policy on medication administration
D. Terminating an employee for repeated medication errors
Correct Answer: B
Rationale: Correct because data collection is an appropriate delegation to a staff
nurse; policy development, data analysis, and disciplinary action remain
management responsibilities.
Q9: A client with a history of domestic violence confides in the nurse that they are
afraid to return home. What is the nurse's priority action?
A. Advise the client to file a police report immediately
B. Provide resources for domestic violence shelters and social services
C. Tell the client that leaving the relationship is the only safe option
D. Contact the client's partner to arrange a safe discharge plan
Correct Answer: B
Rationale: Correct because the nurse must provide nonjudgmental support, safety
planning, and appropriate referrals while respecting the client's autonomy.
Q10: A nurse is supervising a newly licensed nurse who is preparing to administer
insulin for the first time. Which action requires the supervising nurse to intervene?
A. The new nurse verifies the client's identity using two identifiers
B. The new nurse checks the blood glucose level before administering the insulin
, C. The new nurse withdraws regular insulin and NPH insulin into the same syringe
without checking compatibility
D. The new nurse washes hands before entering the client's room
Correct Answer: C
Rationale: Correct because mixing insulins requires knowledge of compatibility and
proper technique; the supervising nurse must ensure the new nurse understands
which insulin to draw up first.
Q11: A client is refusing a blood transfusion based on religious beliefs. The physician
insists the transfusion is necessary to save the client's life. What is the nurse's legal
and ethical obligation?
A. Administer the transfusion because the physician's order takes precedence
B. Support the client's right to refuse treatment and document the refusal
C. Obtain a court order to override the client's refusal
D. Ask the family to consent on the client's behalf
Correct Answer: B
Rationale: Correct because competent adults have the legal right to refuse
treatment; the nurse must advocate for client autonomy while ensuring informed
refusal is documented.
Q12: A nurse is reviewing the assignments for the shift. Which assignment
demonstrates appropriate delegation?
A. Asking the LPN to develop a teaching plan for a client with heart failure
B. Assigning the UAP to perform a sterile dressing change on a postoperative client
C. Asking the LPN to administer oral medications to a group of stable clients
D. Assigning the UAP to evaluate a client's response to a new antihypertensive
medication
Correct Answer: C
Rationale: Correct because administering oral medications to stable clients is within
the LPN's scope of practice; teaching plan development, sterile dressing changes,
and evaluation require RN judgment.
Q13: A nurse is caring for a client who is confused and repeatedly attempts to
remove their IV line. Which nursing intervention is the priority?
A. Apply soft wrist restraints to prevent IV removal
B. Assign a sitter to remain with the client and provide frequent reorientation
C. Sedate the client with a PRN antianxiety medication
D. Remove the IV and convert all medications to oral route
Correct Answer: B
Bundle Actual 2026/2027 with Detailed Rationales |
100% Verified | Pass Guaranteed – A+ Graded
Section 1: Management of Care (18 Questions)
Q1: A nurse is delegating tasks to unlicensed assistive personnel (UAP) on a busy
medical-surgical unit. Which task is appropriate to delegate to the UAP?
A. Administering oral medications to a stable client
B. Assessing a postoperative client's incision for signs of infection
C. Assisting a client with ambulation to the bathroom
D. Teaching a newly diagnosed diabetic client about insulin administration
Correct Answer: C
Rationale: Correct because assisting with ambulation is within the UAP's scope of
practice; medication administration, assessments, and client education require
licensed nursing judgment.
Q2: A client with a new colostomy expresses concern about odor control. Which
nursing action demonstrates client advocacy?
A. Telling the client that odor is unavoidable with a colostomy
B. Providing the client with educational resources on odor-reducing products and
pouching systems
C. Suggesting the client avoid social situations to prevent embarrassment
D. Asking the physician to prescribe a different type of ostomy
Correct Answer: B
Rationale: Correct because advocating for the client involves empowering them with
information and resources to manage their condition and maintain quality of life.
Q3: During a code blue, the charge nurse assigns the primary nurse to document the
event. Which leadership style is being demonstrated?
A. Autocratic
B. Democratic
C. Laissez-faire
D. Situational
Correct Answer: D
,Rationale: Correct because situational leadership adapts to the immediate context;
during a crisis, the charge nurse assigns roles based on the situation and team
members' capabilities.
Q4: A nurse discovers that a colleague has documented vital signs for a client
without actually assessing them. What is the nurse's first action?
A. Confront the colleague in front of the nursing team
B. Report the incident to the state board of nursing immediately
C. Discuss the concern with the colleague privately and report to the charge nurse if
the behavior continues
D. Document the observation in the client's medical record
Correct Answer: C
Rationale: Correct because the nurse should first address the colleague directly
using professional communication; if the behavior persists, it must be escalated to
protect client safety.
Q5: A client scheduled for surgery asks the nurse to witness a living will. What is the
nurse's appropriate response?
A. Agree to witness the document since the client trusts the nurse
B. Refuse and inform the client that witnesses cannot be involved in the client's care
C. Contact the surgeon to witness the document instead
D. Ask the client's family member to serve as the witness
Correct Answer: B
Rationale: Correct because legal standards require that witnesses to advance
directives be impartial and not involved in the client's direct care to avoid conflict of
interest.
Q6: Which action by the nurse demonstrates proper prioritization using Maslow's
hierarchy of needs?
A. Addressing a client's anxiety about an upcoming procedure before assisting with
toileting
B. Providing pain medication to a client reporting a headache of 8/10 before offering
emotional support
C. Teaching a client about discharge dietary restrictions before ensuring the client
can breathe comfortably
D. Arranging a family conference about end-of-life care before ensuring the client is
hydrated
Correct Answer: B
,Rationale: Correct because pain relief addresses a physiological need, which takes
priority over psychosocial needs according to Maslow's hierarchy.
Q7: A nurse is caring for four clients. Which client should the nurse assess first?
A. A client with a blood pressure of 128/82 mmHg who is requesting a sleeping pill
B. A client with a respiratory rate of 28 breaths/min and oxygen saturation of 88% on
room air
C. A client with a scheduled wound dressing change in 30 minutes
D. A client who needs discharge teaching before leaving at noon
Correct Answer: B
Rationale: Correct because the client with tachypnea and hypoxemia has
compromised airway and breathing, which are the highest priority using the ABC
approach.
Q8: A nurse manager is implementing quality improvement on the unit. Which
activity is most appropriate for the manager to delegate to a staff nurse?
A. Analyzing unit-wide infection rate data and presenting findings to administration
B. Collecting data on the incidence of falls over the past quarter
C. Developing a new hospital-wide policy on medication administration
D. Terminating an employee for repeated medication errors
Correct Answer: B
Rationale: Correct because data collection is an appropriate delegation to a staff
nurse; policy development, data analysis, and disciplinary action remain
management responsibilities.
Q9: A client with a history of domestic violence confides in the nurse that they are
afraid to return home. What is the nurse's priority action?
A. Advise the client to file a police report immediately
B. Provide resources for domestic violence shelters and social services
C. Tell the client that leaving the relationship is the only safe option
D. Contact the client's partner to arrange a safe discharge plan
Correct Answer: B
Rationale: Correct because the nurse must provide nonjudgmental support, safety
planning, and appropriate referrals while respecting the client's autonomy.
Q10: A nurse is supervising a newly licensed nurse who is preparing to administer
insulin for the first time. Which action requires the supervising nurse to intervene?
A. The new nurse verifies the client's identity using two identifiers
B. The new nurse checks the blood glucose level before administering the insulin
, C. The new nurse withdraws regular insulin and NPH insulin into the same syringe
without checking compatibility
D. The new nurse washes hands before entering the client's room
Correct Answer: C
Rationale: Correct because mixing insulins requires knowledge of compatibility and
proper technique; the supervising nurse must ensure the new nurse understands
which insulin to draw up first.
Q11: A client is refusing a blood transfusion based on religious beliefs. The physician
insists the transfusion is necessary to save the client's life. What is the nurse's legal
and ethical obligation?
A. Administer the transfusion because the physician's order takes precedence
B. Support the client's right to refuse treatment and document the refusal
C. Obtain a court order to override the client's refusal
D. Ask the family to consent on the client's behalf
Correct Answer: B
Rationale: Correct because competent adults have the legal right to refuse
treatment; the nurse must advocate for client autonomy while ensuring informed
refusal is documented.
Q12: A nurse is reviewing the assignments for the shift. Which assignment
demonstrates appropriate delegation?
A. Asking the LPN to develop a teaching plan for a client with heart failure
B. Assigning the UAP to perform a sterile dressing change on a postoperative client
C. Asking the LPN to administer oral medications to a group of stable clients
D. Assigning the UAP to evaluate a client's response to a new antihypertensive
medication
Correct Answer: C
Rationale: Correct because administering oral medications to stable clients is within
the LPN's scope of practice; teaching plan development, sterile dressing changes,
and evaluation require RN judgment.
Q13: A nurse is caring for a client who is confused and repeatedly attempts to
remove their IV line. Which nursing intervention is the priority?
A. Apply soft wrist restraints to prevent IV removal
B. Assign a sitter to remain with the client and provide frequent reorientation
C. Sedate the client with a PRN antianxiety medication
D. Remove the IV and convert all medications to oral route
Correct Answer: B
