HESI RN EXIT EXAM 2025–2026 OFFICIAL TEST BANK: REAL
EXAM QUESTIONS WITH ACCURATE RATIONALES;
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. - ANSWER--A
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 - ANSWER--B, 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.
1|Page
,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. - ANSWER--B
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. - ANSWER--C
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.
2|Page
,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.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ANSWER--A
Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these
medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan
is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel
movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication
that this client cannot voice her or his needs, so assessment of the bladder is not needed.
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.
3|Page
, 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.
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.
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EXAM QUESTIONS WITH ACCURATE RATIONALES;
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. - ANSWER--A
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 - ANSWER--B, 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.
1|Page
,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. - ANSWER--B
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. - ANSWER--C
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.
2|Page
,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.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ANSWER--A
Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these
medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan
is not necessary as long as safety is ensured. Whether the client needs to void or have a bowel
movement, option C is irrelevant in terms of meeting this client's safety needs. There is no indication
that this client cannot voice her or his needs, so assessment of the bladder is not needed.
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.
3|Page
, 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.
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.
4|Page
