HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2026-2027 ACTUAL EXAM
100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS) |
[Document subtitle]
, Term
Name: Score:
Term 1 of 20
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A.
Tell the client that the blood pressure is high and that the reading needs to be verified by another
nurse. B.
Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication. C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D.
Compare the current reading with the client's previously documented blood pressure readings.
D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete
information about the schedule. Option A is contraindicated if the client wants to continue smoking.
Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential
for this client only and is inconsistent with unit rules.
D
Rationale: Comparing this reading with previous readings will provide information about what is normal
for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option
B is premature. Further assessment is needed to determine if the reading is abnormal for this client.
Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood
pressure reading.
C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as
long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that
the client should not plan a party. Option B puts words in the client's mouth that may not be
accurate. The nurse should support the client's goals rather than telling the client how to spend her
time.
A
Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most
important intervention for the nurse to implement. Option B is indicated but is not a high-priority
intervention. Option C is irrelevant at this time but might be important when determining the client's
risk for contracting the illness. An antidepressant may be indicated, depending on further
assessment, but grief counseling is a better action at this time because grief is an expected reaction to
the loss of a loved one.
2 of 20
The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the
, client does not have an advance directive (AD) on file. What are the nurse's next steps? (Select all that apply.)
A.
Ask the client's cardiologist to come to the hospital and obtain the AD. B.
Ask the client, "Have you considered completing the paperwork for an AD?" C.
Ask the client's spouse to complete the AD. D.
Tell the client, "An AD helps the staff provide care according to your wishes." E.
Call the client's clergy member to make the final decisions for the client.
D
Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been
obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not
provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be
threatening to an older client and will not determine his ability. Option C is not as effective as direct
observation by the nurse.
B, D
Rationale: A living will is one type of advance directive. The living will outlines the medical treatment
the client elects in the event that the client is no longer able to participate in the decision-making
process. As long as the client has capacity, the client is the sole determinant for the AD. While a living
will describes the wishes of the client, it does not have to be obtained from the physician. Clients
may be assisted by the social work staff. The forms can be completed outside of a medical facility and it
is the client's responsibility to provide a copy of the AD to all health care providers.
A, C
Rationale: The client must stay on her back or on the unaffected side, not on the operative side.
Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of
bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm
will help lymph drainage.
D
Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury
to the client and the nurse. Lowering the client to the floor should be done when the client cannot
support his own weight. The client should be placed in a bed or chair only when sufficient help is
available to prevent injury. Option A is important but should be done after the client is in a safe
position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause
chaos on the unit and might alarm the other clients.
LATEST 2026-2027 ACTUAL EXAM
100 QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS) |
[Document subtitle]
, Term
Name: Score:
Term 1 of 20
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A.
Tell the client that the blood pressure is high and that the reading needs to be verified by another
nurse. B.
Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication. C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D.
Compare the current reading with the client's previously documented blood pressure readings.
D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete
information about the schedule. Option A is contraindicated if the client wants to continue smoking.
Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential
for this client only and is inconsistent with unit rules.
D
Rationale: Comparing this reading with previous readings will provide information about what is normal
for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option
B is premature. Further assessment is needed to determine if the reading is abnormal for this client.
Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood
pressure reading.
C
Rationale: Setting goals that bring pleasure is appropriate and should be encouraged by the nurse as
long as the nurse does not perpetuate a client's denial. Option A is a negative response, implying that
the client should not plan a party. Option B puts words in the client's mouth that may not be
accurate. The nurse should support the client's goals rather than telling the client how to spend her
time.
A
Rationale: The client is exhibiting normal grieving behaviors, so referral to a grief counselor is the most
important intervention for the nurse to implement. Option B is indicated but is not a high-priority
intervention. Option C is irrelevant at this time but might be important when determining the client's
risk for contracting the illness. An antidepressant may be indicated, depending on further
assessment, but grief counseling is a better action at this time because grief is an expected reaction to
the loss of a loved one.
2 of 20
The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the
, client does not have an advance directive (AD) on file. What are the nurse's next steps? (Select all that apply.)
A.
Ask the client's cardiologist to come to the hospital and obtain the AD. B.
Ask the client, "Have you considered completing the paperwork for an AD?" C.
Ask the client's spouse to complete the AD. D.
Tell the client, "An AD helps the staff provide care according to your wishes." E.
Call the client's clergy member to make the final decisions for the client.
D
Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been
obtained and provide an opportunity to affirm the skill. Option A may be therapeutic but will not
provide an opportunity to evaluate the client's ability to perform the procedure. Option B may be
threatening to an older client and will not determine his ability. Option C is not as effective as direct
observation by the nurse.
B, D
Rationale: A living will is one type of advance directive. The living will outlines the medical treatment
the client elects in the event that the client is no longer able to participate in the decision-making
process. As long as the client has capacity, the client is the sole determinant for the AD. While a living
will describes the wishes of the client, it does not have to be obtained from the physician. Clients
may be assisted by the social work staff. The forms can be completed outside of a medical facility and it
is the client's responsibility to provide a copy of the AD to all health care providers.
A, C
Rationale: The client must stay on her back or on the unaffected side, not on the operative side.
Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of
bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm
will help lymph drainage.
D
Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury
to the client and the nurse. Lowering the client to the floor should be done when the client cannot
support his own weight. The client should be placed in a bed or chair only when sufficient help is
available to prevent injury. Option A is important but should be done after the client is in a safe
position. Because the client is not supporting himself, option B is impractical. Option C is likely to cause
chaos on the unit and might alarm the other clients.
