HESI PN Exit Exam (Latest 2026 Update)
| 300 Q&As with Rationales | Nursing
HESI Prep
Section 1: Fundamentals of Nursing (Questions 1-50)
1. A nurse is preparing to insert a nasogastric (NG) tube for a client. What is the most appropriate
method to measure the correct length of the tube to be inserted?
A) Nose to umbilicus
B) Nose to ear to xiphoid process
C) Nose to ear to sternum
D) Earlobe to xiphoid process
Answer: B) Nose to ear to xiphoid process
Rationale: The standard method for measuring an NG tube is from the tip of the nose to the
earlobe, and then to the xiphoid process. This provides an estimate of the distance from the nares
to the stomach.
2. A client is on strict bed rest. Which nursing intervention is most important to prevent deep
vein thrombosis (DVT)?
A) Encourage the client to perform ankle pumps and foot circles.
B) Apply sequential compression devices (SCDs).
C) Administer low-dose heparin as prescribed.
D) Massage the calves twice daily.
Answer: B) Apply sequential compression devices (SCDs).
Rationale: SCDs are a highly effective mechanical prophylaxis method that mimics the calf muscle
pump, enhancing venous return and preventing stasis. While ankle pumps (A) are good, SCDs
provide continuous, consistent compression. Heparin (C) is a pharmacological intervention but
isn't always prescribed for all clients. Massaging calves (D) is contraindicated as it can dislodge an
existing clot.
3. A nurse is caring for a client who has a new tracheostomy. Which action is the priority when
providing tracheostomy care?
,A) Ensuring the client can speak.
B) Suctioning the tracheostomy tube as needed.
C) Changing the tracheostomy ties.
D) Maintaining a patent airway.
Answer: D) Maintaining a patent airway.
Rationale: The priority in any respiratory intervention is to maintain a patent (open) airway. All
other actions (suctioning, changing ties, speaking) are secondary to ensuring the client can
breathe effectively.
4. The nurse is assessing a client's skin and notes a localized area of deep red skin over the sacrum
that does not blanch when pressed. How should the nurse document this finding?
A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Stage 3 pressure injury
D) Unstageable pressure injury
Answer: A) Stage 1 pressure injury
Rationale: A Stage 1 pressure injury is characterized by intact skin with non-blanchable redness.
Stage 2 involves partial-thickness skin loss, Stage 3 involves full-thickness skin loss, and
Unstageable involves a wound with slough or eschar covering the full-thickness loss.
5. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's
priority action?
A) Slow the infusion rate and assess vital signs.
B) Stop the transfusion and notify the physician.
C) Stop the transfusion, disconnect the tubing, and infuse normal saline.
D) Administer an antihistamine as prescribed.
Answer: C) Stop the transfusion, disconnect the tubing, and infuse normal saline.
Rationale: Chills and back pain are classic signs of a hemolytic transfusion reaction. The priority is
to stop the transfusion immediately, disconnect the blood tubing to prevent any more blood from
entering, and maintain IV access with normal saline to support blood pressure. Notifying the
physician (B) comes after this action.
,6. A nurse is preparing to administer a medication via a Z-track injection. Which is the correct
technique?
A) Use a 45-degree angle for insertion.
B) Massage the site after injection.
C) Use a 1-inch needle for all patients.
D) Pull the skin laterally before inserting the needle.
Answer: D) Pull the skin laterally before inserting the needle.
Rationale: The Z-track method involves pulling the skin and subcutaneous tissue laterally about 1
inch before inserting the needle. This displaces the tissue and seals the medication in the muscle,
preventing leakage and staining of the subcutaneous tissue. Massaging (B) is avoided in Z-track.
7. A nurse is calculating the intake and output for a client in 8 hours. The client consumed 4 oz of
juice, 8 oz of milk, and 6 oz of tea. They received 250 mL of IV fluids and voided 300 mL. What is
the total intake?
A) 180 mL
B) 430 mL
C) 790 mL
D) 1120 mL
Answer: C) 790 mL
Rationale:
4 oz juice = 4 x 30 mL = 120 mL
8 oz milk = 8 x 30 mL = 240 mL
6 oz tea = 6 x 30 mL = 180 mL
IV fluids = 250 mL
Total Intake = 120 + 240 + 180 + 250 = 790 mL
8. A client post-operative day 1 has an order for "enoxaparin 40 mg subcut daily." What is the best
site for this injection?
A) Ventrogluteal site
B) Vastus lateralis site
C) Abdomen, 2 inches away from the umbilicus
D) Dorsogluteal site
, Answer: C) Abdomen, 2 inches away from the umbilicus
Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin. The preferred site for
subcutaneous injection is the abdomen, in the anterolateral or posterolateral aspect, at least 2
inches away from the umbilicus to avoid injecting into the umbilicus itself.
9. A client is on fall precautions. Which intervention should the nurse implement?
A) Keep the bed in the highest position to facilitate care.
B) Place all personal belongings far from the bed to encourage movement.
C) Ensure the call light is within the client's reach.
D) Use full side rails at all times.
Answer: C) Ensure the call light is within the client's reach.
Rationale: Ensuring the call light is within reach is a standard and crucial fall prevention strategy.
The bed should be in the lowest position (A), personal items should be within reach (B), and full
side rails can be a restraint (D) and are not used as a fall prevention strategy.
10. A nurse is performing a sterile wound dressing change. Which action breaks sterile technique?
A) Opening the sterile package away from the body.
B) Reaching over the sterile field to retrieve an item.
C) Holding sterile objects above the waist.
D) Pouring sterile solution into a sterile basin.
Answer: B) Reaching over the sterile field to retrieve an item.
Rationale: Reaching over the sterile field contaminates it. You should never reach over a sterile
field; you must go around it or use sterile forceps.
11. The nurse is teaching a client with a new colostomy about stoma care. Which statement
indicates the client understands the teaching?
A) "The stoma should be moist and pink."
B) "I will not eat any foods that can cause gas."
C) "I should change my pouch every day."
D) "The stoma should be dark and purplish."
Answer: A) "The stoma should be moist and pink."
Rationale: A healthy stoma is pink/red and moist. A dark, purplish stoma (D) indicates ischemia.
| 300 Q&As with Rationales | Nursing
HESI Prep
Section 1: Fundamentals of Nursing (Questions 1-50)
1. A nurse is preparing to insert a nasogastric (NG) tube for a client. What is the most appropriate
method to measure the correct length of the tube to be inserted?
A) Nose to umbilicus
B) Nose to ear to xiphoid process
C) Nose to ear to sternum
D) Earlobe to xiphoid process
Answer: B) Nose to ear to xiphoid process
Rationale: The standard method for measuring an NG tube is from the tip of the nose to the
earlobe, and then to the xiphoid process. This provides an estimate of the distance from the nares
to the stomach.
2. A client is on strict bed rest. Which nursing intervention is most important to prevent deep
vein thrombosis (DVT)?
A) Encourage the client to perform ankle pumps and foot circles.
B) Apply sequential compression devices (SCDs).
C) Administer low-dose heparin as prescribed.
D) Massage the calves twice daily.
Answer: B) Apply sequential compression devices (SCDs).
Rationale: SCDs are a highly effective mechanical prophylaxis method that mimics the calf muscle
pump, enhancing venous return and preventing stasis. While ankle pumps (A) are good, SCDs
provide continuous, consistent compression. Heparin (C) is a pharmacological intervention but
isn't always prescribed for all clients. Massaging calves (D) is contraindicated as it can dislodge an
existing clot.
3. A nurse is caring for a client who has a new tracheostomy. Which action is the priority when
providing tracheostomy care?
,A) Ensuring the client can speak.
B) Suctioning the tracheostomy tube as needed.
C) Changing the tracheostomy ties.
D) Maintaining a patent airway.
Answer: D) Maintaining a patent airway.
Rationale: The priority in any respiratory intervention is to maintain a patent (open) airway. All
other actions (suctioning, changing ties, speaking) are secondary to ensuring the client can
breathe effectively.
4. The nurse is assessing a client's skin and notes a localized area of deep red skin over the sacrum
that does not blanch when pressed. How should the nurse document this finding?
A) Stage 1 pressure injury
B) Stage 2 pressure injury
C) Stage 3 pressure injury
D) Unstageable pressure injury
Answer: A) Stage 1 pressure injury
Rationale: A Stage 1 pressure injury is characterized by intact skin with non-blanchable redness.
Stage 2 involves partial-thickness skin loss, Stage 3 involves full-thickness skin loss, and
Unstageable involves a wound with slough or eschar covering the full-thickness loss.
5. A client is receiving a blood transfusion and reports chills and back pain. What is the nurse's
priority action?
A) Slow the infusion rate and assess vital signs.
B) Stop the transfusion and notify the physician.
C) Stop the transfusion, disconnect the tubing, and infuse normal saline.
D) Administer an antihistamine as prescribed.
Answer: C) Stop the transfusion, disconnect the tubing, and infuse normal saline.
Rationale: Chills and back pain are classic signs of a hemolytic transfusion reaction. The priority is
to stop the transfusion immediately, disconnect the blood tubing to prevent any more blood from
entering, and maintain IV access with normal saline to support blood pressure. Notifying the
physician (B) comes after this action.
,6. A nurse is preparing to administer a medication via a Z-track injection. Which is the correct
technique?
A) Use a 45-degree angle for insertion.
B) Massage the site after injection.
C) Use a 1-inch needle for all patients.
D) Pull the skin laterally before inserting the needle.
Answer: D) Pull the skin laterally before inserting the needle.
Rationale: The Z-track method involves pulling the skin and subcutaneous tissue laterally about 1
inch before inserting the needle. This displaces the tissue and seals the medication in the muscle,
preventing leakage and staining of the subcutaneous tissue. Massaging (B) is avoided in Z-track.
7. A nurse is calculating the intake and output for a client in 8 hours. The client consumed 4 oz of
juice, 8 oz of milk, and 6 oz of tea. They received 250 mL of IV fluids and voided 300 mL. What is
the total intake?
A) 180 mL
B) 430 mL
C) 790 mL
D) 1120 mL
Answer: C) 790 mL
Rationale:
4 oz juice = 4 x 30 mL = 120 mL
8 oz milk = 8 x 30 mL = 240 mL
6 oz tea = 6 x 30 mL = 180 mL
IV fluids = 250 mL
Total Intake = 120 + 240 + 180 + 250 = 790 mL
8. A client post-operative day 1 has an order for "enoxaparin 40 mg subcut daily." What is the best
site for this injection?
A) Ventrogluteal site
B) Vastus lateralis site
C) Abdomen, 2 inches away from the umbilicus
D) Dorsogluteal site
, Answer: C) Abdomen, 2 inches away from the umbilicus
Rationale: Enoxaparin (Lovenox) is a low-molecular-weight heparin. The preferred site for
subcutaneous injection is the abdomen, in the anterolateral or posterolateral aspect, at least 2
inches away from the umbilicus to avoid injecting into the umbilicus itself.
9. A client is on fall precautions. Which intervention should the nurse implement?
A) Keep the bed in the highest position to facilitate care.
B) Place all personal belongings far from the bed to encourage movement.
C) Ensure the call light is within the client's reach.
D) Use full side rails at all times.
Answer: C) Ensure the call light is within the client's reach.
Rationale: Ensuring the call light is within reach is a standard and crucial fall prevention strategy.
The bed should be in the lowest position (A), personal items should be within reach (B), and full
side rails can be a restraint (D) and are not used as a fall prevention strategy.
10. A nurse is performing a sterile wound dressing change. Which action breaks sterile technique?
A) Opening the sterile package away from the body.
B) Reaching over the sterile field to retrieve an item.
C) Holding sterile objects above the waist.
D) Pouring sterile solution into a sterile basin.
Answer: B) Reaching over the sterile field to retrieve an item.
Rationale: Reaching over the sterile field contaminates it. You should never reach over a sterile
field; you must go around it or use sterile forceps.
11. The nurse is teaching a client with a new colostomy about stoma care. Which statement
indicates the client understands the teaching?
A) "The stoma should be moist and pink."
B) "I will not eat any foods that can cause gas."
C) "I should change my pouch every day."
D) "The stoma should be dark and purplish."
Answer: A) "The stoma should be moist and pink."
Rationale: A healthy stoma is pink/red and moist. A dark, purplish stoma (D) indicates ischemia.
