ULTIMATE HESI RN EXIT EXAM TEST BANK 2025–2026: 100%
EXAM-FOCUSED QUESTIONS WITH DETAILED
EXPLANATIONS;
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
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake - ANSWER--B
1|Page
,Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet,
such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which
are contraindicated for this client.
A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in
the sacral area. Which instruction is most important for the nurse to provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." - ANSWER--B
Rationale: The most important teaching is to change positions frequently because pressure is the
most significant factor related to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
Which nonverbal action should the nurse implement to demonstrate active listening?
A.
Sit facing the client.
B.
Cross arms and legs.
C.
Avoid eye contact.
D.
Lean back in the chair. - ANSWER--A
Rationale: Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing
the client, which lets the client know that the nurse is there to listen. Active listening skills include
postures that are open to the client, such as keeping the arms open and relaxed, not option B, and
leaning toward the client, not option D. To communicate involvement and willingness to listen to the
client, eye contact should be established and maintained.
2|Page
,The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he
states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the
priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. - ANSWER--D
Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent
injury to the client and the nurse. Lowering the client to the floor should be done when the client
cannot support his own weight. The client should be placed in a bed or chair only when sufficient
help is available to prevent injury. Option A is important but should be done after the client is in a
safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to
cause chaos on the unit and might alarm the other clients.
The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The
nurse should be alert for which findings? (Select all that apply.)
A.
Weakness in the hands and feet
B.
+1 reflexes to the patella
C.
Headache
D.
Muscle twitching
E.
Nausea
F.
Facial redness - ANSWER--A, B, C, E
Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle twitching and
facial redness.
3|Page
, The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior
to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding
would the nurse suspect is inaccurate related to the prolonged tourniquet placement?
A.
Na 148 mEq/L
B.
K 5.3 mEq/L
C.
Cl 102 mEq/L
D.
Ca 9.3 mg/dL - ANSWER--B
Rationale: Prolonged tourniquet placement can cause accumulation of potassium, skewing the result
upward. The sodium level is also high, but that is not related to the blood draw. The chloride and
calcium levels are normal.
The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the
attention of the healthcare provider?
A.
Temperature: 97.5°F/36.4°C
B.
Pulse: 80 beats/min
C.
Respirations: 26 breaths/min
D.
Blood pressure: 90/53 mm Hg - ANSWER--B
Rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is below the
normal range. The remaining vital signs are within the normal limits for a 1-year-old.
The clinic nurse is reviewing an antibiotic medication prescribed to a client with a urinary tract
infection. What instructions will the nurse include in the client's teaching? (Select all that apply.)
A.
Take all of the medication as prescribed, especially when you start feeling better.
4|Page
EXAM-FOCUSED QUESTIONS WITH DETAILED
EXPLANATIONS;
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
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake - ANSWER--B
1|Page
,Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a low-fat diet,
such as option B. Option A is a high-protein diet, and options C and D contain high-fat foods, which
are contraindicated for this client.
A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in
the sacral area. Which instruction is most important for the nurse to provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." - ANSWER--B
Rationale: The most important teaching is to change positions frequently because pressure is the
most significant factor related to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
Which nonverbal action should the nurse implement to demonstrate active listening?
A.
Sit facing the client.
B.
Cross arms and legs.
C.
Avoid eye contact.
D.
Lean back in the chair. - ANSWER--A
Rationale: Active listening is conveyed using attentive verbal and nonverbal communication
techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing
the client, which lets the client know that the nurse is there to listen. Active listening skills include
postures that are open to the client, such as keeping the arms open and relaxed, not option B, and
leaning toward the client, not option D. To communicate involvement and willingness to listen to the
client, eye contact should be established and maintained.
2|Page
,The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he
states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the
priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. - ANSWER--D
Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent
injury to the client and the nurse. Lowering the client to the floor should be done when the client
cannot support his own weight. The client should be placed in a bed or chair only when sufficient
help is available to prevent injury. Option A is important but should be done after the client is in a
safe position. Because the client is not supporting himself, option B is impractical. Option C is likely to
cause chaos on the unit and might alarm the other clients.
The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is 128 mEq/L. The
nurse should be alert for which findings? (Select all that apply.)
A.
Weakness in the hands and feet
B.
+1 reflexes to the patella
C.
Headache
D.
Muscle twitching
E.
Nausea
F.
Facial redness - ANSWER--A, B, C, E
Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle twitching and
facial redness.
3|Page
, The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior
to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding
would the nurse suspect is inaccurate related to the prolonged tourniquet placement?
A.
Na 148 mEq/L
B.
K 5.3 mEq/L
C.
Cl 102 mEq/L
D.
Ca 9.3 mg/dL - ANSWER--B
Rationale: Prolonged tourniquet placement can cause accumulation of potassium, skewing the result
upward. The sodium level is also high, but that is not related to the blood draw. The chloride and
calcium levels are normal.
The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the
attention of the healthcare provider?
A.
Temperature: 97.5°F/36.4°C
B.
Pulse: 80 beats/min
C.
Respirations: 26 breaths/min
D.
Blood pressure: 90/53 mm Hg - ANSWER--B
Rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is below the
normal range. The remaining vital signs are within the normal limits for a 1-year-old.
The clinic nurse is reviewing an antibiotic medication prescribed to a client with a urinary tract
infection. What instructions will the nurse include in the client's teaching? (Select all that apply.)
A.
Take all of the medication as prescribed, especially when you start feeling better.
4|Page
