FORTIS COLLEGE NUR100 HESI ACTUAL EXAM – QUESTIONS AND ANSWERS | VERIFIED AND WELL
DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST
1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased
shortness of breath and a productive cough. The nurse notes the client is using accessory muscles to
breathe and has a respiratory rate of 28 breaths per minute. Which intervention should the nurse
implement first?
A. Administer a bronchodilator as prescribed.
B. Place the client in a high Fowler's position.
C. Prepare for endotracheal intubation.
D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: B. Place the client in a high Fowler's position.
Rationale: The immediate priority is to position the client to optimize lung expansion and reduce the work of
breathing. High Fowler's position allows for maximal diaphragmatic descent and is the first non-invasive
intervention to improve ventilation. While administering a bronchodilator (A) is a crucial next step, positioning
is the priority to support breathing mechanics. Preparing for intubation (C) is a later intervention if conservative
measures fail. Obtaining an ABG (D) is important for assessment but does not directly alleviate the client's
immediate respiratory distress.
,2. A nurse is calculating the intake and output for a client over an 8-hour shift. The client consumed 240
mL of coffee, 120 mL of orange juice, and 90 mL of water. The client also received 500 mL of intravenous
fluids. The client's urinary output was 450 mL, and there was 75 mL of drainage from the nasogastric
tube. What is the client's total intake in milliliters?
A. 860 mL
B. 950 mL
C. 545 mL
D. 450 mL
Correct Answer: B. 950 mL
Rationale: Total intake is calculated by summing all fluids consumed and administered intravenously. The oral
intake is 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) = 450 mL. Adding the 500 mL of IV fluids
gives a total intake of 450 mL + 500 mL = 950 mL. Option A (860 mL) is incorrect as it may have omitted the
water. Option C (545 mL) is incorrect as it is likely a miscalculation or only totals oral intake. Option D (450 mL)
is incorrect as it represents the oral intake or output, not the total intake.
,3. A nurse is preparing to administer an intramuscular (IM) injection to an adult client in the ventrogluteal
site. Which action is most important for the nurse to take to ensure safe administration?
A. Use a 1-inch needle for the injection.
B. Identify the landmarks by placing the palm on the greater trochanter.
C. Position the client in a prone position.
D. Aspirate for blood return before injecting the medication.
Correct Answer: D. Aspirate for blood return before injecting the medication.
Rationale: Aspirating for blood return is the most important action to confirm that the needle is not in a blood
vessel, which could lead to intravenous administration of the drug. This is a standard safety practice for IM
injections, especially in sites with large blood vessels. Using a 1-inch needle (A) may be appropriate but depends
on the client's muscle mass; it is not the most important safety action. Identifying landmarks (B) is a crucial step
in locating the correct site, but it is performed before the aspiration step. While the client can be positioned
prone, side-lying, or supine, the positioning is not the most critical safety action once the site has been chosen.
4. A client is receiving a continuous infusion of normal saline at 125 mL/hour. The nurse notices that the
infusion pump is set for 150 mL/hour. Which action should the nurse take first?
, A. Change the pump setting to 125 mL/hour.
B. Assess the client for signs of fluid overload.
C. Notify the healthcare provider.
D. Complete an incident report.
Correct Answer: B. Assess the client for signs of fluid overload.
Rationale: The immediate priority is to assess the client for any adverse effects from the increased infusion rate.
While the pump setting should be corrected, the nurse must first evaluate the client's physiological status to
determine if any acute interventions are needed. Changing the pump setting (A) is the secondary, corrective
action. Notifying the healthcare provider (C) and completing an incident report (D) are important follow-up
actions but are not the primary, immediate intervention after an error is discovered.
5. A nurse is performing a sterile dressing change for a client with a surgical wound. After opening the
sterile supplies and applying sterile gloves, the nurse prepares to clean the wound. Which of the following
actions would indicate a break in sterile technique?
A. The nurse cleans the wound from the center outward.
B. The nurse places the sterile field within 1 inch of the edge of the bedside table.
C. The nurse's sterile gloves touch the inner surface of the sterile drape.
D. The nurse keeps hands above the waist level.
DETAILED ANSWERS | PLUS RATIONALES | GUARANTEED PASS | 2026/27 LATEST UPDATE | EXAM PREP |
STUDY GUIDE | PRACTICE TEST
1. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with increased
shortness of breath and a productive cough. The nurse notes the client is using accessory muscles to
breathe and has a respiratory rate of 28 breaths per minute. Which intervention should the nurse
implement first?
A. Administer a bronchodilator as prescribed.
B. Place the client in a high Fowler's position.
C. Prepare for endotracheal intubation.
D. Obtain an arterial blood gas (ABG) sample.
Correct Answer: B. Place the client in a high Fowler's position.
Rationale: The immediate priority is to position the client to optimize lung expansion and reduce the work of
breathing. High Fowler's position allows for maximal diaphragmatic descent and is the first non-invasive
intervention to improve ventilation. While administering a bronchodilator (A) is a crucial next step, positioning
is the priority to support breathing mechanics. Preparing for intubation (C) is a later intervention if conservative
measures fail. Obtaining an ABG (D) is important for assessment but does not directly alleviate the client's
immediate respiratory distress.
,2. A nurse is calculating the intake and output for a client over an 8-hour shift. The client consumed 240
mL of coffee, 120 mL of orange juice, and 90 mL of water. The client also received 500 mL of intravenous
fluids. The client's urinary output was 450 mL, and there was 75 mL of drainage from the nasogastric
tube. What is the client's total intake in milliliters?
A. 860 mL
B. 950 mL
C. 545 mL
D. 450 mL
Correct Answer: B. 950 mL
Rationale: Total intake is calculated by summing all fluids consumed and administered intravenously. The oral
intake is 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) = 450 mL. Adding the 500 mL of IV fluids
gives a total intake of 450 mL + 500 mL = 950 mL. Option A (860 mL) is incorrect as it may have omitted the
water. Option C (545 mL) is incorrect as it is likely a miscalculation or only totals oral intake. Option D (450 mL)
is incorrect as it represents the oral intake or output, not the total intake.
,3. A nurse is preparing to administer an intramuscular (IM) injection to an adult client in the ventrogluteal
site. Which action is most important for the nurse to take to ensure safe administration?
A. Use a 1-inch needle for the injection.
B. Identify the landmarks by placing the palm on the greater trochanter.
C. Position the client in a prone position.
D. Aspirate for blood return before injecting the medication.
Correct Answer: D. Aspirate for blood return before injecting the medication.
Rationale: Aspirating for blood return is the most important action to confirm that the needle is not in a blood
vessel, which could lead to intravenous administration of the drug. This is a standard safety practice for IM
injections, especially in sites with large blood vessels. Using a 1-inch needle (A) may be appropriate but depends
on the client's muscle mass; it is not the most important safety action. Identifying landmarks (B) is a crucial step
in locating the correct site, but it is performed before the aspiration step. While the client can be positioned
prone, side-lying, or supine, the positioning is not the most critical safety action once the site has been chosen.
4. A client is receiving a continuous infusion of normal saline at 125 mL/hour. The nurse notices that the
infusion pump is set for 150 mL/hour. Which action should the nurse take first?
, A. Change the pump setting to 125 mL/hour.
B. Assess the client for signs of fluid overload.
C. Notify the healthcare provider.
D. Complete an incident report.
Correct Answer: B. Assess the client for signs of fluid overload.
Rationale: The immediate priority is to assess the client for any adverse effects from the increased infusion rate.
While the pump setting should be corrected, the nurse must first evaluate the client's physiological status to
determine if any acute interventions are needed. Changing the pump setting (A) is the secondary, corrective
action. Notifying the healthcare provider (C) and completing an incident report (D) are important follow-up
actions but are not the primary, immediate intervention after an error is discovered.
5. A nurse is performing a sterile dressing change for a client with a surgical wound. After opening the
sterile supplies and applying sterile gloves, the nurse prepares to clean the wound. Which of the following
actions would indicate a break in sterile technique?
A. The nurse cleans the wound from the center outward.
B. The nurse places the sterile field within 1 inch of the edge of the bedside table.
C. The nurse's sterile gloves touch the inner surface of the sterile drape.
D. The nurse keeps hands above the waist level.
