HESI FUNDAMENTALS EXIT EXAM 2025/2026 |
COMPLETE TEST BANK (VERSIONS 1, 2 & 3) WITH
100% VERIFIED ANSWERS AND DETAILED
RATIONALES | GRADED A+
VERSION 1
Q1. A postoperative client returns to the unit after general anesthesia. Which
assessment finding requires the nurse's immediate attention?
A. Respiratory rate 10 breaths/min, shallow
B. Blood pressure 118/76 mm Hg
C. Oxygen saturation 96% on room air
D. Client sleeping and difficult to arouse for 10 minutes after arrival
Answer: A. Respiratory rate 10 breaths/min, shallow
Rationale: Respiratory depression is a common early postoperative complication
of general anesthesia and can cause hypoventilation and hypoxia; a rate of 10 and
shallow respirations require immediate intervention.
Q2. A client with heart failure has gained 4 pounds in 3 days. Which nursing
action is priority?
A. Encourage the client to ambulate more
B. Notify the healthcare provider and assess for edema and breath sounds
C. Restrict oral fluids immediately
D. Increase the client's dietary potassium
Answer: B. Notify the healthcare provider and assess for edema and breath sounds
Rationale: Rapid weight gain indicates fluid retention; assessing for signs of fluid
overload (edema, crackles) and notifying the provider are priorities for timely
management.
,Q3. The nurse is preparing to give an IM injection to an adult. Which site provides
the most reliable muscle mass for large-volume injections?
A. Deltoid muscle
B. Dorsogluteal site
C. Ventrogluteal site
D. Vastus lateralis
Answer: C. Ventrogluteal site
Rationale: The ventrogluteal site is recommended for large-volume IM injections
in adults due to abundant muscle and low risk of nerve or vascular injury.
Q4. A client who is NPO is scheduled for surgery at 0900. Which preoperative
instruction is appropriate the night before?
A. Allow the client to drink coffee at 0700 the morning of surgery
B. Instruct the client to have nothing to eat or drink after midnight
C. Encourage a high-fat breakfast the morning of surgery
D. Permit chewing gum up until arrival at the OR
Answer: B. Instruct the client to have nothing to eat or drink after midnight
Rationale: Standard NPO instructions reduce aspiration risk during anesthesia;
clear liquids may be allowed up to a few hours before surgery per facility policy,
but the traditional instruction is NPO after midnight.
Q5. A nurse notes a medication error (wrong dose given) that caused no harm.
What is the nurse’s best action?
A. Document the error in the client’s chart and notify the healthcare provider and
manager per policy
B. Do nothing if the client is fine
C. Discuss the error only with the client’s family
D. Transfer responsibility to another nurse
Answer: A. Document the error in the client’s chart and notify the healthcare
provider and manager per policy
Rationale: Ethical and legal practice requires reporting and documenting
medication errors, regardless of harm, to promote client safety and meet
institutional policy.
,Q6. Which of the following actions best reduces nosocomial infection transmission
from a nurse to patients?
A. Wearing gloves only when touching blood
B. Performing hand hygiene before and after patient contact
C. Wearing shoe covers in the unit
D. Changing uniform daily
Answer: B. Performing hand hygiene before and after patient contact
Rationale: Hand hygiene is the most effective method to prevent healthcare-
associated infections and should be done before/after patient contact and after
removing PPE.
Q7. A client with diabetes is to receive 10 units of regular insulin and 18 units of
NPH insulin SQ at 0800. How should the nurse administer?
A. Draw up NPH first then regular in same syringe
B. Draw up regular first then NPH in same syringe
C. Give both injections in the same site without mixing
D. Mix only if client prefers
Answer: B. Draw up regular first then NPH in same syringe
Rationale: When mixing regular and NPH insulin, withdraw the short-acting
(regular) insulin first to avoid contaminating the regular vial with NPH, preserving
insulin onset.
Q8. The nurse observes another staff member taking a photo of a client with a
personal phone and posting it to social media. What is the appropriate action?
A. Ignore—it's none of your business
B. Report the incident to the unit manager and document as a privacy breach
C. Like the post to appear supportive
D. Invite others to comment
Answer: B. Report the incident to the unit manager and document as a privacy
breach
Rationale: Posting client photos without consent breaches confidentiality and
HIPAA; the nurse must report and document the privacy violation.
, Q9. A client with COPD uses accessory muscles to breathe and has an SpO₂ of
88% on room air. Which immediate action should the nurse take?
A. Place the client in high Fowler’s position and administer supplemental oxygen
per order
B. Encourage deep breathing and coughing only
C. Give a bolus of IV fluids
D. Restrict activity further
Answer: A. Place the client in high Fowler’s position and administer supplemental
oxygen per order
Rationale: Positioning to maximize ventilation and providing prescribed oxygen
improve oxygenation in respiratory distress (monitor for CO2 retention in COPD
per order).
Q10. Which medication is the nurse most concerned about when documenting a
client who has received heparin therapy and has a platelet count of 60,000/mm³?
A. Aspirin
B. Acetaminophen
C. Insulin
D. Albuterol
Answer: A. Aspirin
Rationale: Aspirin increases bleeding risk when combined with heparin;
thrombocytopenia (platelets 60,000) raises concern for bleeding and heparin-
induced thrombocytopenia.
Q11. A client with a urinary catheter reports discomfort and a low-grade fever.
Which data collection is priority?
A. Check urine color and odor and obtain a urine specimen for culture
B. Assess for history of allergies
C. Evaluate bowel sounds
D. Measure peripheral capillary refill
Answer: A. Check urine color and odor and obtain a urine specimen for culture
Rationale: Catheter-associated urinary tract infection is likely; assessing urine and
obtaining culture guide treatment.
COMPLETE TEST BANK (VERSIONS 1, 2 & 3) WITH
100% VERIFIED ANSWERS AND DETAILED
RATIONALES | GRADED A+
VERSION 1
Q1. A postoperative client returns to the unit after general anesthesia. Which
assessment finding requires the nurse's immediate attention?
A. Respiratory rate 10 breaths/min, shallow
B. Blood pressure 118/76 mm Hg
C. Oxygen saturation 96% on room air
D. Client sleeping and difficult to arouse for 10 minutes after arrival
Answer: A. Respiratory rate 10 breaths/min, shallow
Rationale: Respiratory depression is a common early postoperative complication
of general anesthesia and can cause hypoventilation and hypoxia; a rate of 10 and
shallow respirations require immediate intervention.
Q2. A client with heart failure has gained 4 pounds in 3 days. Which nursing
action is priority?
A. Encourage the client to ambulate more
B. Notify the healthcare provider and assess for edema and breath sounds
C. Restrict oral fluids immediately
D. Increase the client's dietary potassium
Answer: B. Notify the healthcare provider and assess for edema and breath sounds
Rationale: Rapid weight gain indicates fluid retention; assessing for signs of fluid
overload (edema, crackles) and notifying the provider are priorities for timely
management.
,Q3. The nurse is preparing to give an IM injection to an adult. Which site provides
the most reliable muscle mass for large-volume injections?
A. Deltoid muscle
B. Dorsogluteal site
C. Ventrogluteal site
D. Vastus lateralis
Answer: C. Ventrogluteal site
Rationale: The ventrogluteal site is recommended for large-volume IM injections
in adults due to abundant muscle and low risk of nerve or vascular injury.
Q4. A client who is NPO is scheduled for surgery at 0900. Which preoperative
instruction is appropriate the night before?
A. Allow the client to drink coffee at 0700 the morning of surgery
B. Instruct the client to have nothing to eat or drink after midnight
C. Encourage a high-fat breakfast the morning of surgery
D. Permit chewing gum up until arrival at the OR
Answer: B. Instruct the client to have nothing to eat or drink after midnight
Rationale: Standard NPO instructions reduce aspiration risk during anesthesia;
clear liquids may be allowed up to a few hours before surgery per facility policy,
but the traditional instruction is NPO after midnight.
Q5. A nurse notes a medication error (wrong dose given) that caused no harm.
What is the nurse’s best action?
A. Document the error in the client’s chart and notify the healthcare provider and
manager per policy
B. Do nothing if the client is fine
C. Discuss the error only with the client’s family
D. Transfer responsibility to another nurse
Answer: A. Document the error in the client’s chart and notify the healthcare
provider and manager per policy
Rationale: Ethical and legal practice requires reporting and documenting
medication errors, regardless of harm, to promote client safety and meet
institutional policy.
,Q6. Which of the following actions best reduces nosocomial infection transmission
from a nurse to patients?
A. Wearing gloves only when touching blood
B. Performing hand hygiene before and after patient contact
C. Wearing shoe covers in the unit
D. Changing uniform daily
Answer: B. Performing hand hygiene before and after patient contact
Rationale: Hand hygiene is the most effective method to prevent healthcare-
associated infections and should be done before/after patient contact and after
removing PPE.
Q7. A client with diabetes is to receive 10 units of regular insulin and 18 units of
NPH insulin SQ at 0800. How should the nurse administer?
A. Draw up NPH first then regular in same syringe
B. Draw up regular first then NPH in same syringe
C. Give both injections in the same site without mixing
D. Mix only if client prefers
Answer: B. Draw up regular first then NPH in same syringe
Rationale: When mixing regular and NPH insulin, withdraw the short-acting
(regular) insulin first to avoid contaminating the regular vial with NPH, preserving
insulin onset.
Q8. The nurse observes another staff member taking a photo of a client with a
personal phone and posting it to social media. What is the appropriate action?
A. Ignore—it's none of your business
B. Report the incident to the unit manager and document as a privacy breach
C. Like the post to appear supportive
D. Invite others to comment
Answer: B. Report the incident to the unit manager and document as a privacy
breach
Rationale: Posting client photos without consent breaches confidentiality and
HIPAA; the nurse must report and document the privacy violation.
, Q9. A client with COPD uses accessory muscles to breathe and has an SpO₂ of
88% on room air. Which immediate action should the nurse take?
A. Place the client in high Fowler’s position and administer supplemental oxygen
per order
B. Encourage deep breathing and coughing only
C. Give a bolus of IV fluids
D. Restrict activity further
Answer: A. Place the client in high Fowler’s position and administer supplemental
oxygen per order
Rationale: Positioning to maximize ventilation and providing prescribed oxygen
improve oxygenation in respiratory distress (monitor for CO2 retention in COPD
per order).
Q10. Which medication is the nurse most concerned about when documenting a
client who has received heparin therapy and has a platelet count of 60,000/mm³?
A. Aspirin
B. Acetaminophen
C. Insulin
D. Albuterol
Answer: A. Aspirin
Rationale: Aspirin increases bleeding risk when combined with heparin;
thrombocytopenia (platelets 60,000) raises concern for bleeding and heparin-
induced thrombocytopenia.
Q11. A client with a urinary catheter reports discomfort and a low-grade fever.
Which data collection is priority?
A. Check urine color and odor and obtain a urine specimen for culture
B. Assess for history of allergies
C. Evaluate bowel sounds
D. Measure peripheral capillary refill
Answer: A. Check urine color and odor and obtain a urine specimen for culture
Rationale: Catheter-associated urinary tract infection is likely; assessing urine and
obtaining culture guide treatment.
