HESI PN EXIT Exam ACTUAL EXAM –
Complete 80 Questions & Verified
Answers Latest Update –
Already Graded A
Fundamentals of Nursing (Questions 1-12)
1. A post-operative client complains of sudden severe calf pain. Which nursing
action is most appropriate?
A. Massage the calf vigorously to promote circulation
B. Apply a cold compress and elevate the extremity
C. Notify the provider immediately and keep the client in bed
D. Encourage the client to dorsiflex the foot hourly
Correct Answer: C
Rationale: Sudden calf pain may indicate deep vein thrombosis (DVT). Massaging (A)
could dislodge a clot; cold (B) does not address the emergency; dorsiflexion exercises
(D) are contraindicated until DVT is ruled out. Immediate provider notification and
bed-rest (C) prevent embolism.
2. When assessing a client with an indwelling urinary catheter, the nurse notes urine
leaking around the catheter. The first action is to
, A. remove the current catheter and insert a new one
B. check for catheter kinks or traction on the tubing
C. inflate the balloon with an additional 5 mL of sterile water
D. apply an incontinence pad and document the leakage
Correct Answer: B
Rationale: Mechanical obstruction (kink, traction) increases intravesical pressure and
causes bypass leakage. Correcting tubing issues (B) restores drainage; unnecessary
re-insertion (A) increases infection risk; over-inflating (C) can irritate the urethra;
padding (D) does not solve the cause.
3. A client is receiving oxygen via nasal cannula at 4 L/min. Which assessment
finding requires immediate intervention?
A. Nasal mucosa slightly pink
B. Oxygen saturation 89 %
C. Client reports mild nasal dryness
D. Flow-meter ball centered at 4 L/min mark
Correct Answer: B
Rationale: SpO₂ 89 % is below the acceptable 92 % threshold and indicates hypoxemia.
Mild dryness (C) and pink mucosa (A) are expected; centered flow meter (D) is correct.
4. The nurse prepares to administer a cleansing enema to an adult client. The
safest fluid temperature range is
A. 98.6 °F to 102 °F
B. 105 °F to 110 °F
C. 80 °F to 85 °F
D. 75 °F to 80 °F
,Correct Answer: A
Rationale: Solutions at body temperature prevent rectal mucosa trauma and vagal
stimulation. Temperatures > 105 °F (B) can burn; cool solutions (C, D) cause cramping.
5. Which action best maintains surgical asepsis while opening a sterile package?
A. Hold the outer 1-inch border with clean gloves
B. Open the first flap toward the nurse’s body
C. Keep the inner contents 12 inches above waist level
D. Place the package on a clean bedside table before opening
Correct Answer: C
Rationale: Sterile items must remain above waist (12 inches) to avoid contamination
from airborne particles. Opening toward the body (B) violates principles; outer border
(A) is unsterile; table (D) is not a sterile field.
6. A client’s morning oral temperature is 96.8 °F (36 °C). The nurse should first
A. Re-check rectally after breakfast
B. Assess for hypothyroid symptoms
C. Document the finding and continue to monitor
D. Apply warming blankets immediately
Correct Answer: C
Rationale: 96.8 °F is low-normal and may reflect individual variation or environmental
factors; no acute intervention is required unless symptomatic. Immediate warming (D)
or rectal re-check (A) is invasive and unnecessary without other data; hypothyroid
assessment (B) is premature.
, 7. The nurse hears a loud “pop” when turning a client and the client screams in pain.
The affected leg is shorter and externally rotated. The nurse suspects
A. Hip dislocation
B. Fractured femur
C. Heterotopic ossification
D. Sciatic nerve injury
Correct Answer: B
Rationale: Classic signs of fractured proximal femur: shortening, external rotation,
audible crack. Dislocation (A) usually produces internal rotation; nerve injury (D) does
not shorten limb.
8. A client on bed-rest develops a red, tender area on the sacrum. The nurse
documents this as
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Unstageable pressure injury
D. Deep-tissue injury
Correct Answer: A
Rationale: Non-blanchable erythema with intact skin defines Stage 1. Stage 2 (B)
involves partial-thickness skin loss; unstageable (C) has obscured wound bed;
deep-tissue (D) presents with purple discoloration.
9. When using a pulse oximeter, the nurse should place the probe
A. On a cool, cyanotic finger
B. Over an acrylic fingernail
Complete 80 Questions & Verified
Answers Latest Update –
Already Graded A
Fundamentals of Nursing (Questions 1-12)
1. A post-operative client complains of sudden severe calf pain. Which nursing
action is most appropriate?
A. Massage the calf vigorously to promote circulation
B. Apply a cold compress and elevate the extremity
C. Notify the provider immediately and keep the client in bed
D. Encourage the client to dorsiflex the foot hourly
Correct Answer: C
Rationale: Sudden calf pain may indicate deep vein thrombosis (DVT). Massaging (A)
could dislodge a clot; cold (B) does not address the emergency; dorsiflexion exercises
(D) are contraindicated until DVT is ruled out. Immediate provider notification and
bed-rest (C) prevent embolism.
2. When assessing a client with an indwelling urinary catheter, the nurse notes urine
leaking around the catheter. The first action is to
, A. remove the current catheter and insert a new one
B. check for catheter kinks or traction on the tubing
C. inflate the balloon with an additional 5 mL of sterile water
D. apply an incontinence pad and document the leakage
Correct Answer: B
Rationale: Mechanical obstruction (kink, traction) increases intravesical pressure and
causes bypass leakage. Correcting tubing issues (B) restores drainage; unnecessary
re-insertion (A) increases infection risk; over-inflating (C) can irritate the urethra;
padding (D) does not solve the cause.
3. A client is receiving oxygen via nasal cannula at 4 L/min. Which assessment
finding requires immediate intervention?
A. Nasal mucosa slightly pink
B. Oxygen saturation 89 %
C. Client reports mild nasal dryness
D. Flow-meter ball centered at 4 L/min mark
Correct Answer: B
Rationale: SpO₂ 89 % is below the acceptable 92 % threshold and indicates hypoxemia.
Mild dryness (C) and pink mucosa (A) are expected; centered flow meter (D) is correct.
4. The nurse prepares to administer a cleansing enema to an adult client. The
safest fluid temperature range is
A. 98.6 °F to 102 °F
B. 105 °F to 110 °F
C. 80 °F to 85 °F
D. 75 °F to 80 °F
,Correct Answer: A
Rationale: Solutions at body temperature prevent rectal mucosa trauma and vagal
stimulation. Temperatures > 105 °F (B) can burn; cool solutions (C, D) cause cramping.
5. Which action best maintains surgical asepsis while opening a sterile package?
A. Hold the outer 1-inch border with clean gloves
B. Open the first flap toward the nurse’s body
C. Keep the inner contents 12 inches above waist level
D. Place the package on a clean bedside table before opening
Correct Answer: C
Rationale: Sterile items must remain above waist (12 inches) to avoid contamination
from airborne particles. Opening toward the body (B) violates principles; outer border
(A) is unsterile; table (D) is not a sterile field.
6. A client’s morning oral temperature is 96.8 °F (36 °C). The nurse should first
A. Re-check rectally after breakfast
B. Assess for hypothyroid symptoms
C. Document the finding and continue to monitor
D. Apply warming blankets immediately
Correct Answer: C
Rationale: 96.8 °F is low-normal and may reflect individual variation or environmental
factors; no acute intervention is required unless symptomatic. Immediate warming (D)
or rectal re-check (A) is invasive and unnecessary without other data; hypothyroid
assessment (B) is premature.
, 7. The nurse hears a loud “pop” when turning a client and the client screams in pain.
The affected leg is shorter and externally rotated. The nurse suspects
A. Hip dislocation
B. Fractured femur
C. Heterotopic ossification
D. Sciatic nerve injury
Correct Answer: B
Rationale: Classic signs of fractured proximal femur: shortening, external rotation,
audible crack. Dislocation (A) usually produces internal rotation; nerve injury (D) does
not shorten limb.
8. A client on bed-rest develops a red, tender area on the sacrum. The nurse
documents this as
A. Stage 1 pressure injury
B. Stage 2 pressure injury
C. Unstageable pressure injury
D. Deep-tissue injury
Correct Answer: A
Rationale: Non-blanchable erythema with intact skin defines Stage 1. Stage 2 (B)
involves partial-thickness skin loss; unstageable (C) has obscured wound bed;
deep-tissue (D) presents with purple discoloration.
9. When using a pulse oximeter, the nurse should place the probe
A. On a cool, cyanotic finger
B. Over an acrylic fingernail
