RN HESI EXIT EXAM VERSION 2 ACTUAL TEST
2026 SOLUTIONS VERIFIED A+
◉ 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.
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.
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.
2026 SOLUTIONS VERIFIED A+
◉ 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.
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.
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.
