HESI RN FUNDAMENTALS EXIT EXAM LATEST 2026-2027
ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIED ANSWERS)
Question and answer
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.
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 - CORRECT ANSWERB
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. - CORRECT ANSWERB
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. - CORRECT ANSWERA
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 administered 10 mg of diazepam to the preoperative client. What steps will the nurse take
next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - CORRECT ANSWERB, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by placing the client close
to the nurse's station is not necessary. The medication has a sedative effect and the client should not get
out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is
the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
, B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. - CORRECT ANSWERB
Rationale: The nurse should first assess the client's feelings about death and determine the extent to
which this statement expresses the client's true feelings. The client may need additional pain
management, but further assessment is needed before implementing option A. Options C and D are both
premature interventions and should not be implemented until further assessment is obtained.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and
applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg
amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach, causation, and damages) can
be proved. - CORRECT ANSWERC
Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and
provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's
Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of
Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions
taken in the emergency were not done in good faith or that reasonable care was not provided. All four
elements of malpractice were not shown.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now
requesting to go to the bathroom. What is the priority nursing action for this client?
A.
ACTUAL EXAM 100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES (VERIFIED ANSWERS)
Question and answer
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.
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 - CORRECT ANSWERB
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. - CORRECT ANSWERB
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. - CORRECT ANSWERA
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 administered 10 mg of diazepam to the preoperative client. What steps will the nurse take
next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - CORRECT ANSWERB, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by placing the client close
to the nurse's station is not necessary. The medication has a sedative effect and the client should not get
out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is
the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
, B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. - CORRECT ANSWERB
Rationale: The nurse should first assess the client's feelings about death and determine the extent to
which this statement expresses the client's true feelings. The client may need additional pain
management, but further assessment is needed before implementing option A. Options C and D are both
premature interventions and should not be implemented until further assessment is obtained.
A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and
applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg
amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach, causation, and damages) can
be proved. - CORRECT ANSWERC
Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and
provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's
Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of
Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions
taken in the emergency were not done in good faith or that reasonable care was not provided. All four
elements of malpractice were not shown.
An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now
requesting to go to the bathroom. What is the priority nursing action for this client?
A.
