HESI RN EXIT EXAM TEST BANK 2025–2026 | UPDATED
QUESTIONS & VERIFIED RATIONALES;
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.)
1|Page
,A.
Take all of the medication as prescribed, especially when you start feeling better.
B.
Take the medication with 8 ounce/240 mL of water.
C.
Call poison control if you start itching, develop hives, or have difficulty breathing.
D.
Keep this medication out of the reach of small children, preferably in a locked cabinet.
E.
Call your healthcare provider (HCP) when your symptoms subside. - ANSWER--A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics. The client
needs to take the full course of antibiotics to achieve the maximum effect. Drinking a glass of water
will help keep the body hydrated. All medication should be kept out of reach, preferably in a locked
cabinet. The client needs to call the health care provider in the event of an allergic reaction to the
antibiotic. The medication is prescribed to treat the infection. There is no need to notify the HCP
when the medication is having the desired effects.
The nurse is aware that malnutrition is a common problem among clients served by a community
health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic
protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level - ANSWER--A
Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin
levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly
alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with
an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
2|Page
,A.
Tell the client that the blood pressure is high and that the reading needs to be verified by another
nurse.
B.
Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication.
C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort.
D.
Compare the current reading with the client's previously documented blood pressure readings. -
ANSWER--D
Rationale: Comparing this reading with previous readings will provide information about what is
normal for this client; this action should be taken first. Option A might unnecessarily alarm the client.
Option B is premature. Further assessment is needed to determine if the reading is abnormal for this
client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a
blood pressure reading.
The nurse comes upon an automobile accident involving many cars. Which victim should the nurse
see first?
A.
The victim who is not breathing and does not have a pulse
B.
The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare
C.
The victim who is heavily bleeding bright red blood from a thigh wound
D.
The victim who is crying, complaining of arm pain, and no other apparent injuries - ANSWER--C
Rationale: The client hemorrhaging from the leg wound is the priority as of the severely injured
clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to
the wound site. When there is only one health care provider on the scene, the nurse must provide
care to those who are most likely to survive. The client without a pulse and respirations is dead. The
client with bleeding from the ears, nose, and mouth, with a blank stare, likely has severe head
trauma. The victim with arm pain and crying is the lowest priority.
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, The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the
consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps
must the nurse take? (Select all that apply.)
A.
Call the surgeon.
B.
Ask the client, "Did your surgeon explain the procedure to you?"
C.
Have the client's spouse sign the form.
D.
Ask the client, "Do you have any questions?"
E.
Witness the signature.
F.
Obtain the consent. - ANSWER--B, D, E
Rationale:It is the surgeon's responsibility to review the procedure with the client until the client has
no further questions. The nurse can verify the review by the surgeon and ask if the client has any
further questions. If the client has questions, the nurse must call in the surgeon. When the nurse
signs the consent form, the nurse is witnessing the signature only.
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
A.
Check the bath water temperature.
B.
Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. - ANSWER--A
Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature.
Options B, C, and D promote comfort and privacy and are important interventions but are of less
priority than promoting safety
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QUESTIONS & VERIFIED RATIONALES;
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.)
1|Page
,A.
Take all of the medication as prescribed, especially when you start feeling better.
B.
Take the medication with 8 ounce/240 mL of water.
C.
Call poison control if you start itching, develop hives, or have difficulty breathing.
D.
Keep this medication out of the reach of small children, preferably in a locked cabinet.
E.
Call your healthcare provider (HCP) when your symptoms subside. - ANSWER--A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics. The client
needs to take the full course of antibiotics to achieve the maximum effect. Drinking a glass of water
will help keep the body hydrated. All medication should be kept out of reach, preferably in a locked
cabinet. The client needs to call the health care provider in the event of an allergic reaction to the
antibiotic. The medication is prescribed to treat the infection. There is no need to notify the HCP
when the medication is having the desired effects.
The nurse is aware that malnutrition is a common problem among clients served by a community
health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic
protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level - ANSWER--A
Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin
levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein
breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly
alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with
an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition.
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
2|Page
,A.
Tell the client that the blood pressure is high and that the reading needs to be verified by another
nurse.
B.
Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication.
C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort.
D.
Compare the current reading with the client's previously documented blood pressure readings. -
ANSWER--D
Rationale: Comparing this reading with previous readings will provide information about what is
normal for this client; this action should be taken first. Option A might unnecessarily alarm the client.
Option B is premature. Further assessment is needed to determine if the reading is abnormal for this
client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a
blood pressure reading.
The nurse comes upon an automobile accident involving many cars. Which victim should the nurse
see first?
A.
The victim who is not breathing and does not have a pulse
B.
The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare
C.
The victim who is heavily bleeding bright red blood from a thigh wound
D.
The victim who is crying, complaining of arm pain, and no other apparent injuries - ANSWER--C
Rationale: The client hemorrhaging from the leg wound is the priority as of the severely injured
clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to
the wound site. When there is only one health care provider on the scene, the nurse must provide
care to those who are most likely to survive. The client without a pulse and respirations is dead. The
client with bleeding from the ears, nose, and mouth, with a blank stare, likely has severe head
trauma. The victim with arm pain and crying is the lowest priority.
3|Page
, The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the
consent form, the nurse notes the surgeon's signature, but not the client's signature. What steps
must the nurse take? (Select all that apply.)
A.
Call the surgeon.
B.
Ask the client, "Did your surgeon explain the procedure to you?"
C.
Have the client's spouse sign the form.
D.
Ask the client, "Do you have any questions?"
E.
Witness the signature.
F.
Obtain the consent. - ANSWER--B, D, E
Rationale:It is the surgeon's responsibility to review the procedure with the client until the client has
no further questions. The nurse can verify the review by the surgeon and ask if the client has any
further questions. If the client has questions, the nurse must call in the surgeon. When the nurse
signs the consent form, the nurse is witnessing the signature only.
In assisting an older adult client prepare to take a tub bath, which nursing action is most important?
A.
Check the bath water temperature.
B.
Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. - ANSWER--A
Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature.
Options B, C, and D promote comfort and privacy and are important interventions but are of less
priority than promoting safety
4|Page
