HESI RN EXIT EXAM PREP 2025–2026: COMPREHENSIVE
TEST BANK WITH VERIFIED ANSWERS & STUDY STRATEGIES
The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has
the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ANSWER--D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is a problem that
may develop from having an indwelling catheter. Option B may or may not be true for the client.
Option C is not affected by an indwelling catheter.
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - ANSWER--C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that
could harbor bacteria. The child's cognitive development may not be at the level at which option A
would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is
not indicated and may be perceived as intrusive.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse
take first when given the assignment?
A.
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,Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - ANSWER--B
Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when
possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C,
A, and D should be addressed.
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which
documentation should the nurse use to identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - ANSWER--B
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that
is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV
access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the
dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are
not recommended for IV access. Option D is not specific enough for documenting the location of the
IV access.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following
surgery and notes that an antihypertensive medication that was prescribed preoperatively is not
listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
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,Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
D.
Contact the health care provider to renew the prescription for the medication. - ANSWER--D
Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the health care provider if the antihypertensive medication is not included in the
postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions.
The nurse must have a current prescription before administering any medications.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the
first time the client has voided in 4 hours. Which action should the nurse take next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention. - ANSWER--A
Rationale: The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output, but no additional action is needed.
The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's
suggestions to quench the client's thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
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, E.
Keep a few pieces of hard candy with you to suck on. - ANSWER--B, C, E
Rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in them that
draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming frozen
liquids. Hard candy can produce moisture in the mouth.
The nurse notes in the client's plan of care altered sleep patterns related to nocturia. Which nursing
actions are important for the nurse to provide? (Select all that apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern. - ANSWER--A, E
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of
urine, thus decreasing the need to void at night. Option E gives the nurse the client's baseline sleep
pattern. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will
contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does
not awaken to void.
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six
respirations and the client coughs three times. In repeating the count for a second 30-second
interval, the nurse counts eight respirations. Which respiratory rate will the nurse document?
A. 15
B. 16
C. 17
D. 28 - ANSWER--B
Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was
not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled.
Options A, C, and D are inaccurate recordings.
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TEST BANK WITH VERIFIED ANSWERS & STUDY STRATEGIES
The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has
the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ANSWER--D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is a problem that
may develop from having an indwelling catheter. Option B may or may not be true for the client.
Option C is not affected by an indwelling catheter.
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
Ask the parents why the child is not circumcised. - ANSWER--C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all areas that
could harbor bacteria. The child's cognitive development may not be at the level at which option A
would be effective. Perineal care needs to be provided daily regardless of the client's age. Option D is
not indicated and may be perceived as intrusive.
A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse
take first when given the assignment?
A.
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,Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - ANSWER--B
Rationale: Caring for a close friend can violate boundaries for nurses and should be avoided when
possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C,
A, and D should be addressed.
The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which
documentation should the nurse use to identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - ANSWER--B
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of the vein that
is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV
access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the
dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are
not recommended for IV access. Option D is not specific enough for documenting the location of the
IV access.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following
surgery and notes that an antihypertensive medication that was prescribed preoperatively is not
listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
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,Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
D.
Contact the health care provider to renew the prescription for the medication. - ANSWER--D
Rationale: Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the health care provider if the antihypertensive medication is not included in the
postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions.
The nurse must have a current prescription before administering any medications.
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the
first time the client has voided in 4 hours. Which action should the nurse take next?
A.
Record the amount on the client's fluid output record.
B.
Encourage the client to increase oral fluid intake.
C.
Notify the health care provider of the findings.
D.
Palpate the client's bladder for distention. - ANSWER--A
Rationale: The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output, but no additional action is needed.
The client states to the nurse, "This medication makes my mouth so dry." What are the nurse's
suggestions to quench the client's thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
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, E.
Keep a few pieces of hard candy with you to suck on. - ANSWER--B, C, E
Rationale: Sodas do not tend to be thirst quenching because of the amount of sugar in them that
draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming frozen
liquids. Hard candy can produce moisture in the mouth.
The nurse notes in the client's plan of care altered sleep patterns related to nocturia. Which nursing
actions are important for the nurse to provide? (Select all that apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern. - ANSWER--A, E
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of
urine, thus decreasing the need to void at night. Option E gives the nurse the client's baseline sleep
pattern. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will
contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does
not awaken to void.
The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six
respirations and the client coughs three times. In repeating the count for a second 30-second
interval, the nurse counts eight respirations. Which respiratory rate will the nurse document?
A. 15
B. 16
C. 17
D. 28 - ANSWER--B
Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was
not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled.
Options A, C, and D are inaccurate recordings.
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