, BSN 366 EXIT HESI EXAM Complete
Question Bank with Answers &
Rationales Updated for 2026 | 530+
Questions | Graded A+
Question 1:
A nurse is receiving change-of-shift report on a medical-surgical unit. Which client
should the nurse assess FIRST?
A) A client with a small bowel obstruction who has a nasogastric tube draining greenish
fluid
B) A client with an obstruction of the large intestine who is experiencing abdominal
distention
C) A client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
D) A client who had surgery yesterday and is experiencing a paralytic ileus with absent
bowel sounds
Answer: C) A client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity
Rationale: Abdominal rigidity in a client with a volvulus indicates peritonitis or bowel
ischemia, which is a medical emergency requiring immediate surgical intervention. While
all options involve gastrointestinal complications, rigidity is the most concerning sign of
potential bowel perforation.
Question 2:
After receiving report on an inpatient acute care unit, which client should the nurse
assess FIRST?
A) An older adult client who is receiving packed red blood cells on the third day post-
operative for colon resection
B) An adult client with continuous bladder irrigation who is two days post-operative for
,bladder surgery
C) An adult client in Buck's traction scheduled for hip arthroplasty within the next 12
hours
D) An adult client one day post-operative laparoscopic cholecystectomy requesting pain
medication
Answer: A) An older adult client who is receiving packed red blood cells on the
third day post-operative for colon resection
Rationale: A client receiving a blood transfusion is at risk for transfusion reactions,
which can be life-threatening. The nurse should assess this client first to monitor for
signs of reaction such as fever, chills, or dyspnea. The other clients have stable
conditions or expected findings.
Question 3:
Which task can the nurse assign to an unlicensed assistive personnel (UAP)?
A) Assess the IV infusion site for complications
B) Monitor the rate of a continuous enteral feeding
C) Measure the client's intake and output
D) Evaluate the effectiveness of client education
Answer: C) Measure the client's intake and output
Rationale: UAPs can perform delegated tasks such as measuring intake and output,
obtaining vital signs, and assisting with activities of daily living. Assessment, evaluation,
and monitoring of infusions require the professional judgment of the nurse and cannot
be delegated.
Question 4:
A nurse is caring for four clients. Which client should the nurse assess FIRST?
A) A client with COPD who has an oxygen saturation of 91%
B) A client with diabetes mellitus who has a blood glucose of 180 mg/dL
C) A client with heart failure who has crackles in the lung bases
D) A client with a urinary tract infection who has a temperature of 100.4°F
, Answer: C) A client with heart failure who has crackles in the lung bases
Rationale: Crackles in the lung bases indicate pulmonary congestion, a sign of
worsening heart failure that requires immediate intervention. This is a priority
assessment using the ABC (Airway, Breathing, Circulation) framework.
Question 5:
A nurse is delegating tasks to a UAP. Which task is appropriate to delegate?
A) Assisting a client with ambulation using a gait belt
B) Administering oral medications to a stable client
C) Assessing a client's pain level
D) Educating a client about dietary restrictions
Answer: A) Assisting a client with ambulation using a gait belt
Rationale: UAPs can assist with ambulation and activities of daily living. Medication
administration, pain assessment, and client education require the professional judgment
of the nurse and cannot be delegated.
Question 6:
A nurse is assisting a client with ambulation using a gait belt when the client begins to
fall. What action should the nurse take?
A) Grab the client's arms to prevent the fall
B) Step behind the client and guide the client to the floor
C) Call for help immediately
D) Allow the client to fall to the floor
Answer: B) Step behind the client and guide the client to the floor
Rationale: When a client begins to fall, the nurse should step behind the client, widen
the base of support, and guide the client to the floor to control the fall and minimize
injury. Grabbing the client's arms could cause injury, and allowing the fall to occur
without guidance is unsafe.
Question Bank with Answers &
Rationales Updated for 2026 | 530+
Questions | Graded A+
Question 1:
A nurse is receiving change-of-shift report on a medical-surgical unit. Which client
should the nurse assess FIRST?
A) A client with a small bowel obstruction who has a nasogastric tube draining greenish
fluid
B) A client with an obstruction of the large intestine who is experiencing abdominal
distention
C) A client with a bowel obstruction due to a volvulus who is experiencing abdominal
rigidity
D) A client who had surgery yesterday and is experiencing a paralytic ileus with absent
bowel sounds
Answer: C) A client with a bowel obstruction due to a volvulus who is experiencing
abdominal rigidity
Rationale: Abdominal rigidity in a client with a volvulus indicates peritonitis or bowel
ischemia, which is a medical emergency requiring immediate surgical intervention. While
all options involve gastrointestinal complications, rigidity is the most concerning sign of
potential bowel perforation.
Question 2:
After receiving report on an inpatient acute care unit, which client should the nurse
assess FIRST?
A) An older adult client who is receiving packed red blood cells on the third day post-
operative for colon resection
B) An adult client with continuous bladder irrigation who is two days post-operative for
,bladder surgery
C) An adult client in Buck's traction scheduled for hip arthroplasty within the next 12
hours
D) An adult client one day post-operative laparoscopic cholecystectomy requesting pain
medication
Answer: A) An older adult client who is receiving packed red blood cells on the
third day post-operative for colon resection
Rationale: A client receiving a blood transfusion is at risk for transfusion reactions,
which can be life-threatening. The nurse should assess this client first to monitor for
signs of reaction such as fever, chills, or dyspnea. The other clients have stable
conditions or expected findings.
Question 3:
Which task can the nurse assign to an unlicensed assistive personnel (UAP)?
A) Assess the IV infusion site for complications
B) Monitor the rate of a continuous enteral feeding
C) Measure the client's intake and output
D) Evaluate the effectiveness of client education
Answer: C) Measure the client's intake and output
Rationale: UAPs can perform delegated tasks such as measuring intake and output,
obtaining vital signs, and assisting with activities of daily living. Assessment, evaluation,
and monitoring of infusions require the professional judgment of the nurse and cannot
be delegated.
Question 4:
A nurse is caring for four clients. Which client should the nurse assess FIRST?
A) A client with COPD who has an oxygen saturation of 91%
B) A client with diabetes mellitus who has a blood glucose of 180 mg/dL
C) A client with heart failure who has crackles in the lung bases
D) A client with a urinary tract infection who has a temperature of 100.4°F
, Answer: C) A client with heart failure who has crackles in the lung bases
Rationale: Crackles in the lung bases indicate pulmonary congestion, a sign of
worsening heart failure that requires immediate intervention. This is a priority
assessment using the ABC (Airway, Breathing, Circulation) framework.
Question 5:
A nurse is delegating tasks to a UAP. Which task is appropriate to delegate?
A) Assisting a client with ambulation using a gait belt
B) Administering oral medications to a stable client
C) Assessing a client's pain level
D) Educating a client about dietary restrictions
Answer: A) Assisting a client with ambulation using a gait belt
Rationale: UAPs can assist with ambulation and activities of daily living. Medication
administration, pain assessment, and client education require the professional judgment
of the nurse and cannot be delegated.
Question 6:
A nurse is assisting a client with ambulation using a gait belt when the client begins to
fall. What action should the nurse take?
A) Grab the client's arms to prevent the fall
B) Step behind the client and guide the client to the floor
C) Call for help immediately
D) Allow the client to fall to the floor
Answer: B) Step behind the client and guide the client to the floor
Rationale: When a client begins to fall, the nurse should step behind the client, widen
the base of support, and guide the client to the floor to control the fall and minimize
injury. Grabbing the client's arms could cause injury, and allowing the fall to occur
without guidance is unsafe.
