HESI RN EXIT EXAM 2025–2026 MASTER TEST BANK:
UPDATED QUESTIONS, RATIONALES & PASS-GUARANTEE
REVIEW
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.
The nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to
administering the feeding? (Select all that apply.)
1|Page
,A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
C.
Position the client in semi-Fowler's position.
D.
Irrigate the lumen after the contents are replaced.
E.
Warm the feeding to room temperature.
F.
Assess the pH of the stomach contents. - ANSWER--A, B, E, F
Rationale: The client needs to be in high Fowler's position to decrease the risk of aspiration.
Irrigation of the lumen is only necessary if there is an obstruction. The contents were replaced, so
there is no suspicion of obstruction. The remaining steps are correct.
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens
will be coming to get me soon!" and falls asleep. Which action should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
B.
Assess the client's neurologic status.
C.
Notify the surgeon about the comment.
D.
Ask the client's family to co-sign the operative permit. - ANSWER--B
Rationale: This statement may indicate that the client is confused. Informed consent must be
provided by a mentally competent individual, so the nurse should further assess the client's
neurologic status to be sure that the client understands and can legally provide consent for surgery.
Option A does not provide sufficient follow-up. If the nurse determines that the client is confused,
the surgeon must be notified and permission obtained from the next of kin.
When turning an immobile bedridden client without assistance, which action by the nurse best
ensures client safety?
2|Page
,A.
Securely grasp the client's arm and leg.
B.
Put bed rails up on the side of bed opposite from the nurse.
C.
Correctly position and use a turn sheet.
D.
Lower the head of the client's bed slowly. - ANSWER--B
Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to
the skin or joint. Options C and D are useful techniques while turning a client but have less priority in
terms of safety than use of the bed rails.
A community hospital is opening a mental health services department. Which document should the
nurse use to develop the unit's nursing guidelines?
A.
Americans with Disabilities Act of 1990
B.
ANA Code of Ethics with Interpretative Statements
C.
ANA's Scope and Standards of Nursing Practice
D.
Patient's Bill of Rights of 1990 - ANSWER--C
Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to
direct the philosophy and standards of psychiatric nursing practice. Options A and D define the
client's rights. Option B provides ethical guidelines for nursing.
The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse
consider when administering PN? (Select all that apply.)
A.
Remove the PN from the refrigerator 30 minutes before infusing.
B.
Have a second nurse double check the PN before connecting the solution.
3|Page
, C.
Have a second IV line in place for administering IV medications.
D.
Assure the infusion time for the PN does not exceed 24 hours.
E.
Tell the client a feeling of being full should occur with PN.
F.
Return amber and cloudy solutions of PN to the pharmacy. - ANSWER--A, D, F
Rationale: There are no issues with antibody incompatibility with PN, so there is no need to double
check the PN, or start a second IV line. PN is administered through the venous system and does not
satiate the client. The remaining selections are true about the administration of PN.
The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for an
80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What
supplies will the nurse take into the room for this procedure? (Select all that apply.)
A.
A 16 gauge IV catheter
B.
Normal saline in a 10 mL syringe
C.
Clear plastic sterile bandage
D.
Skin preparation antiseptic swab
E.
1000 mL bag of normal saline - ANSWER--B, C, D
Rationale: Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old are
a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions. A small
bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed to start an
IV.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the
dietary needs of this client?
A.
Steak, baked beans, and a salad
4|Page
UPDATED QUESTIONS, RATIONALES & PASS-GUARANTEE
REVIEW
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.
The nurse is preparing to administer a bolus tube feeding. What steps must the nurse include prior to
administering the feeding? (Select all that apply.)
1|Page
,A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
C.
Position the client in semi-Fowler's position.
D.
Irrigate the lumen after the contents are replaced.
E.
Warm the feeding to room temperature.
F.
Assess the pH of the stomach contents. - ANSWER--A, B, E, F
Rationale: The client needs to be in high Fowler's position to decrease the risk of aspiration.
Irrigation of the lumen is only necessary if there is an obstruction. The contents were replaced, so
there is no suspicion of obstruction. The remaining steps are correct.
Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens
will be coming to get me soon!" and falls asleep. Which action should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
B.
Assess the client's neurologic status.
C.
Notify the surgeon about the comment.
D.
Ask the client's family to co-sign the operative permit. - ANSWER--B
Rationale: This statement may indicate that the client is confused. Informed consent must be
provided by a mentally competent individual, so the nurse should further assess the client's
neurologic status to be sure that the client understands and can legally provide consent for surgery.
Option A does not provide sufficient follow-up. If the nurse determines that the client is confused,
the surgeon must be notified and permission obtained from the next of kin.
When turning an immobile bedridden client without assistance, which action by the nurse best
ensures client safety?
2|Page
,A.
Securely grasp the client's arm and leg.
B.
Put bed rails up on the side of bed opposite from the nurse.
C.
Correctly position and use a turn sheet.
D.
Lower the head of the client's bed slowly. - ANSWER--B
Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the
opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to
the skin or joint. Options C and D are useful techniques while turning a client but have less priority in
terms of safety than use of the bed rails.
A community hospital is opening a mental health services department. Which document should the
nurse use to develop the unit's nursing guidelines?
A.
Americans with Disabilities Act of 1990
B.
ANA Code of Ethics with Interpretative Statements
C.
ANA's Scope and Standards of Nursing Practice
D.
Patient's Bill of Rights of 1990 - ANSWER--C
Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves to
direct the philosophy and standards of psychiatric nursing practice. Options A and D define the
client's rights. Option B provides ethical guidelines for nursing.
The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse
consider when administering PN? (Select all that apply.)
A.
Remove the PN from the refrigerator 30 minutes before infusing.
B.
Have a second nurse double check the PN before connecting the solution.
3|Page
, C.
Have a second IV line in place for administering IV medications.
D.
Assure the infusion time for the PN does not exceed 24 hours.
E.
Tell the client a feeling of being full should occur with PN.
F.
Return amber and cloudy solutions of PN to the pharmacy. - ANSWER--A, D, F
Rationale: There are no issues with antibody incompatibility with PN, so there is no need to double
check the PN, or start a second IV line. PN is administered through the venous system and does not
satiate the client. The remaining selections are true about the administration of PN.
The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for an
80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What
supplies will the nurse take into the room for this procedure? (Select all that apply.)
A.
A 16 gauge IV catheter
B.
Normal saline in a 10 mL syringe
C.
Clear plastic sterile bandage
D.
Skin preparation antiseptic swab
E.
1000 mL bag of normal saline - ANSWER--B, C, D
Rationale: Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old are
a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions. A small
bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed to start an
IV.
The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the
dietary needs of this client?
A.
Steak, baked beans, and a salad
4|Page
