HESI RN FUNDAMENTALS EXIT
EXAM LATEST
2025-2026 ACTUAL EXAM 100
QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
The nurse is called to the waiting room of a pediatric clinic. The frantic
"I think states,
mother 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.
E
Perform
. a blind finger sweep.( correct answers ) B,
C, D
Rationale: The fingers are placed at the same location on an
infant as chestfor CPR; however, the nurse must deliver five chest
compressions
thrusts,
five backafter
slaps.
theBlind sweeps are not used as this action may push the
object
into thedeeper
throat. The remaining steps are
correct.
Which fluid will the nurse select to administer with the prescribed blood
A.
transfusion?
5% Dextrose and
water
B
Normal
.
saline
C
.
Lactated Ringers
solution
D
5%. Dextrose and lactated ringers ( correct
answers ) Normal
Rationale: B saline solution is the only solution that is compatible
with blood.
When assisting a client from the bed to a chair, which procedure is best
for the nurse
to
follow?
A
.Place the chair parallel to the bed, with its back toward the head of the
bed client
the and assist
in moving to the
chair.
GRADED
A+
, B
With
. the nurse's feet spread apart and knees aligned with the client's
knees,the
pivot stand
client
and
into the
chair.
C
Assist
. the client to a standing position by gently lifting upward, underneath
the
D axillae.
Stand
. beside the client, place the client's arms around the nurse's neck,
and gently
move the client to the chair. ( correct
answers ) Option
Rationale: B B describes the correct positioning of the nurse and
affordsathe
nurse wide base of support while stabilizing the client's knees when
assisting position.
standing to a The chair should be placed at a 45-degree angle to the
bed, with
back of the thechair toward the head of the bed. Clients should never be
lifted under
axillae; this could
the damage nerves and strain the nurse's back. The
client should
instructed to be
use the arms of the chair and should never place his or her
armsnurse's
the aroundneck; this places undue stress on the nurse's neck and back
and risk
the increases
for a fall.
How many mL will the nurse document on the client's intake and output
record
the from
items listed? _____
mL
1200 mL
4 ounce container of
water
gelatin
8 ounces of orange
juice
355 mL can of soda1 cup of soup ( correct answers )
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155
The nurse
Which observesofa this
observation UAPprocedure
taking a client's
requiresblood pressure
the nurse in the lower
to intervene with
extremity.
the UAP's
approach
A.
?
The cuff wraps around the girth of
the
B leg.
The
. UAP auscultates the popliteal pulse with the cuff on the
lower
C leg.
The
. client is placed in a prone
position.
D
The
. systolic reading is 20 mm Hg higher than the blood pressure in the
client's answers
correct arm. )
( ationale: When obtaining the blood pressure in the lower extremities,
R
B
the popliteal
pulse is the site for auscultation when the blood pressure cuff is applied
aroundThe
thigh. the nurse should intervene with the UAP who has applied the cuff
on the
leg. lowerA ensures an accurate assessment, and option C provides the
Option
best
to theaccess
artery. Systolic pressure in the popliteal artery is usually 10 to 40
mm Hg
than higher
in the brachial
artery.
GRADED
A+
,During a clinic visit, the mother of a 7-year-old reports to the nurse that
her child is often awake until midnight playing and is then very difficult
to awaken in the morning for school. Which assessment data should the
nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep
apnea B.
The child's blood pressure, pulse, and
respirations C.
Length of rapid eye movement (REM) sleep that the child is
experiencing D.
Description of the family's home environment ( correct answers )
D 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.
degree) and full-thickness (third-degree) burns. What action has the highest
The nurse
priority
decreasingin identifies a potential
the client's risk of for infection in a client with partial-
thickness (second-
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
answers ) Careful
Rationale: B handwashing technique is the single most effective
intervention
the prevention forof contamination to all clients. Option A reverses the
hypovolemia
initially that
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
prevent infection.
to
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
healthy. Whatis should the nurse do
next?
A.
Apply a warm compress proximal to
the
B site.
.
Check for kinks in the tubing and raise the
IV
C pole.
.
GRADED
A+
, Adjust the tape that stabilizes the
needle.
D
Flush
. with normal saline and recount the drop rate. ( correct
answers ) The
Rationale: B nurse should first check the tubing and height of the bag
on theare
which IV pole,
common factors that may slow the rate. Gravity
infusion rates
influenced by the
are height of the bag, tubing clamp closure or kinks,
needle size
position, fluid
or viscosity, client blood pressure (crying in the pediatric
client), and Venospasm can slow the rate and often responds to
infiltration.
warmth but
vessel, overthethenurse should first adjust the IV pole height. The nurse
may need
adjust the tostabilizing 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
to prevent
on ways
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
answers ) Performing
Rationale: A 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
the stepstake
nurse will next? (Select all that
A.
apply.)
Place the client in the bed next to the nurse's
station.
B
Instruct
. the client not to get out
of
C bed.
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 answers )
B, C, D Diazepam is a common preoperative medication. Close
Rationale:
observation
placing by
the client close to the nurse's station is not necessary. The
medication
sedative has and
effect a the client should not get out of bed, even with
assistance.selections
remaining The are
correct.
GRADED
A+
EXAM LATEST
2025-2026 ACTUAL EXAM 100
QUESTIONS AND CORRECT
ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
The nurse is called to the waiting room of a pediatric clinic. The frantic
"I think states,
mother 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.
E
Perform
. a blind finger sweep.( correct answers ) B,
C, D
Rationale: The fingers are placed at the same location on an
infant as chestfor CPR; however, the nurse must deliver five chest
compressions
thrusts,
five backafter
slaps.
theBlind sweeps are not used as this action may push the
object
into thedeeper
throat. The remaining steps are
correct.
Which fluid will the nurse select to administer with the prescribed blood
A.
transfusion?
5% Dextrose and
water
B
Normal
.
saline
C
.
Lactated Ringers
solution
D
5%. Dextrose and lactated ringers ( correct
answers ) Normal
Rationale: B saline solution is the only solution that is compatible
with blood.
When assisting a client from the bed to a chair, which procedure is best
for the nurse
to
follow?
A
.Place the chair parallel to the bed, with its back toward the head of the
bed client
the and assist
in moving to the
chair.
GRADED
A+
, B
With
. the nurse's feet spread apart and knees aligned with the client's
knees,the
pivot stand
client
and
into the
chair.
C
Assist
. the client to a standing position by gently lifting upward, underneath
the
D axillae.
Stand
. beside the client, place the client's arms around the nurse's neck,
and gently
move the client to the chair. ( correct
answers ) Option
Rationale: B B describes the correct positioning of the nurse and
affordsathe
nurse wide base of support while stabilizing the client's knees when
assisting position.
standing to a The chair should be placed at a 45-degree angle to the
bed, with
back of the thechair toward the head of the bed. Clients should never be
lifted under
axillae; this could
the damage nerves and strain the nurse's back. The
client should
instructed to be
use the arms of the chair and should never place his or her
armsnurse's
the aroundneck; this places undue stress on the nurse's neck and back
and risk
the increases
for a fall.
How many mL will the nurse document on the client's intake and output
record
the from
items listed? _____
mL
1200 mL
4 ounce container of
water
gelatin
8 ounces of orange
juice
355 mL can of soda1 cup of soup ( correct answers )
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155
The nurse
Which observesofa this
observation UAPprocedure
taking a client's
requiresblood pressure
the nurse in the lower
to intervene with
extremity.
the UAP's
approach
A.
?
The cuff wraps around the girth of
the
B leg.
The
. UAP auscultates the popliteal pulse with the cuff on the
lower
C leg.
The
. client is placed in a prone
position.
D
The
. systolic reading is 20 mm Hg higher than the blood pressure in the
client's answers
correct arm. )
( ationale: When obtaining the blood pressure in the lower extremities,
R
B
the popliteal
pulse is the site for auscultation when the blood pressure cuff is applied
aroundThe
thigh. the nurse should intervene with the UAP who has applied the cuff
on the
leg. lowerA ensures an accurate assessment, and option C provides the
Option
best
to theaccess
artery. Systolic pressure in the popliteal artery is usually 10 to 40
mm Hg
than higher
in the brachial
artery.
GRADED
A+
,During a clinic visit, the mother of a 7-year-old reports to the nurse that
her child is often awake until midnight playing and is then very difficult
to awaken in the morning for school. Which assessment data should the
nurse obtain in response to the mother's concern?
A.
The occurrence of any episodes of sleep
apnea B.
The child's blood pressure, pulse, and
respirations C.
Length of rapid eye movement (REM) sleep that the child is
experiencing D.
Description of the family's home environment ( correct answers )
D 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.
degree) and full-thickness (third-degree) burns. What action has the highest
The nurse
priority
decreasingin identifies a potential
the client's risk of for infection in a client with partial-
thickness (second-
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
answers ) Careful
Rationale: B handwashing technique is the single most effective
intervention
the prevention forof contamination to all clients. Option A reverses the
hypovolemia
initially that
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
prevent infection.
to
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
healthy. Whatis should the nurse do
next?
A.
Apply a warm compress proximal to
the
B site.
.
Check for kinks in the tubing and raise the
IV
C pole.
.
GRADED
A+
, Adjust the tape that stabilizes the
needle.
D
Flush
. with normal saline and recount the drop rate. ( correct
answers ) The
Rationale: B nurse should first check the tubing and height of the bag
on theare
which IV pole,
common factors that may slow the rate. Gravity
infusion rates
influenced by the
are height of the bag, tubing clamp closure or kinks,
needle size
position, fluid
or viscosity, client blood pressure (crying in the pediatric
client), and Venospasm can slow the rate and often responds to
infiltration.
warmth but
vessel, overthethenurse should first adjust the IV pole height. The nurse
may need
adjust the tostabilizing 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
to prevent
on ways
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
answers ) Performing
Rationale: A 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
the stepstake
nurse will next? (Select all that
A.
apply.)
Place the client in the bed next to the nurse's
station.
B
Instruct
. the client not to get out
of
C bed.
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 answers )
B, C, D Diazepam is a common preoperative medication. Close
Rationale:
observation
placing by
the client close to the nurse's station is not necessary. The
medication
sedative has and
effect a the client should not get out of bed, even with
assistance.selections
remaining The are
correct.
GRADED
A+
