HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2025-2026 ACTUAL EXAM
The nurse transcribes the postoperative prescriptions for a client who returns to the
unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
D.
Contact the health care provider to renew the prescription for the medication. -
ANS ... D
Rationale: Medications prescribed preoperatively must be renewed
postoperatively, so the nurse should contact the health care provider if the
antihypertensive medication is not included in the postoperative prescriptions. The
pharmacist does not prescribe medications or renew prescriptions. The nurse must
have a current prescription before administering any medications.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
,C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers - ANS ... B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and
assist the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand
and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the
axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently
move the client to the chair. - ANS ... B
Rationale: Option B describes the correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the client's knees when assisting to a
standing position. The chair should be placed at a 45-degree angle to the bed,
with the back of the chair toward the head of the bed. Clients should never be
lifted under the axillae; this could damage nerves and strain the nurse's back. The
client should be instructed to use the arms of the chair and should never place his or
her arms around the nurse's neck; this places undue stress on the nurse's neck and
back and increases the risk for a fall.
,The nurse is called to the waiting room of a pediatric clinic. The frantic mother
states, "I think my 4-month-old baby is choking!" What steps will the nurse take?
(Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. - ANS ... B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
compressions for CPR; however, the nurse must deliver five chest thrusts, after the
five back slaps. Blind sweeps are not used as this action may push the object
deeper into the throat. The remaining steps are correct.
How many mL will the nurse document on the client's intake and output record from
the items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup - ANS ... Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity.
Which observation of this procedure requires the nurse to intervene with the UAP's
approach?
, A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm. -
ANS ... B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal
pulse is the site for auscultation when the blood pressure cuff is applied around the
thigh. The nurse should intervene with the UAP who has applied the cuff on the
lower leg. Option A ensures an accurate assessment, and option C provides the best
access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm
Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is
often awake until midnight playing and is then very difficult to awaken in the
morning for school. Which assessment data should the nurse obtain in response to
the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - ANS ... D
Rationale: School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that may not be
LATEST 2025-2026 ACTUAL EXAM
The nurse transcribes the postoperative prescriptions for a client who returns to the
unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
Withhold the medication until the client is fully alert and vital signs are stable.
D.
Contact the health care provider to renew the prescription for the medication. -
ANS ... D
Rationale: Medications prescribed preoperatively must be renewed
postoperatively, so the nurse should contact the health care provider if the
antihypertensive medication is not included in the postoperative prescriptions. The
pharmacist does not prescribe medications or renew prescriptions. The nurse must
have a current prescription before administering any medications.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
,C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers - ANS ... B
Rationale: Normal saline solution is the only solution that is compatible with blood.
When assisting a client from the bed to a chair, which procedure is best for the
nurse to follow?
A.
Place the chair parallel to the bed, with its back toward the head of the bed and
assist the client in moving to the chair.
B.
With the nurse's feet spread apart and knees aligned with the client's knees, stand
and pivot the client into the chair.
C.
Assist the client to a standing position by gently lifting upward, underneath the
axillae.
D.
Stand beside the client, place the client's arms around the nurse's neck, and gently
move the client to the chair. - ANS ... B
Rationale: Option B describes the correct positioning of the nurse and affords the
nurse a wide base of support while stabilizing the client's knees when assisting to a
standing position. The chair should be placed at a 45-degree angle to the bed,
with the back of the chair toward the head of the bed. Clients should never be
lifted under the axillae; this could damage nerves and strain the nurse's back. The
client should be instructed to use the arms of the chair and should never place his or
her arms around the nurse's neck; this places undue stress on the nurse's neck and
back and increases the risk for a fall.
,The nurse is called to the waiting room of a pediatric clinic. The frantic mother
states, "I think my 4-month-old baby is choking!" What steps will the nurse take?
(Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. - ANS ... B, C, D
Rationale: The fingers are placed at the same location on an infant as chest
compressions for CPR; however, the nurse must deliver five chest thrusts, after the
five back slaps. Blind sweeps are not used as this action may push the object
deeper into the throat. The remaining steps are correct.
How many mL will the nurse document on the client's intake and output record from
the items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup - ANS ... Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
The nurse observes a UAP taking a client's blood pressure in the lower extremity.
Which observation of this procedure requires the nurse to intervene with the UAP's
approach?
, A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C.
The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm. -
ANS ... B
Rationale: When obtaining the blood pressure in the lower extremities, the popliteal
pulse is the site for auscultation when the blood pressure cuff is applied around the
thigh. The nurse should intervene with the UAP who has applied the cuff on the
lower leg. Option A ensures an accurate assessment, and option C provides the best
access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm
Hg higher than in the brachial artery.
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is
often awake until midnight playing and is then very difficult to awaken in the
morning for school. Which assessment data should the nurse obtain in response to
the mother's concern?
A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - ANS ... D
Rationale: School-age children often resist bedtime. The nurse should begin by
assessing the environment of the home to determine factors that may not be
