HESI EXIT V2 130 Q&A 2026
1. The nurse knows that which statement by the mother indicates that the
mother understands safety precautions with her four month-old infant
and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to
play with my
4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks
stuck up in the air
While the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle
in the kitchen
While I make supper."
The correct answer is D: "I have the four year-old hold and help feed
the four month-old a bottle in the kitchen
2. Upon completing the admission documents, the nurse learns that the
87 year-old client does not have an advance directive. What action
should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
The correct answer is B: Give information about advance directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within
15 minutes after
The immunization was given, the client complains of itchy and watery
eyes, increased
Anxiety, and difficulty breathing. The nurse expects that the first action in
the sequence of
Care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
,The correct answer is B: Administer epinephrine 1:1000 as ordered .
4. Which of these children at the site of a disaster at a child day care
center would the triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying
episodes
,B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper
leg fracture
D) A school-age child with singed eyebrows and hair on the arms
The correct answer is B: A toddler with severe deep abrasions over 98%
of the body .
5. When admitting a client to an acute care facility, an identification
bracelet is sent up
With the admission form. In the event these do not match, the nurse’s
best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office and wait to apply the
bracelet
6. The nurse is having difficulty reading the health care provider's written
order that was written right before the shift change. What action should
be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
The correct answer is D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. After
checking for
Responsiveness and calling for help, the next action that should be
taken by the nurse is to:
A) Check the carotid pulse
B) Deliver 5 abdominal thrusts
C) Give 2 rescue breaths
D) Open the client's airway
The correct answer is D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. The
nurse discovers that 800 ml has been infused after 4 hours. What is
the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
The correct answer is D: Auscultate the lungs
9. Following change-of-shift report on an orthopedic unit, which
client should the nurse see first?
, A) 16 year-old who had an open reduction of a fractured wrist 10 hours
ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle
accident C) 72 year-old recovering from surgery after a hip replacement 2
hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning
surgery. The correct answer is C: 72 year-old recovering from surgery
after a hip replacement 2 hours ago
10. A nurse observes a family member administer a rectal suppository by
having the
Client lie on the left side for the administration. The family member
pushed the
Suppository until the finger went up to the second knuckle. After 10
minutes the client
Was told by the family member to turn to the right side and the client
did this. What is the appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the
insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have
any problems with the insertion?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus
(MRSA) has
Died. Which type of precautions is the appropriate type to use
when performing postmortem care?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Compromised host precautions
The correct answer is C: contact precautions
12. The nurse is reviewing with a client how to collect a clean catch urine
specimen.
Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) Clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
The correct answer is B: clean the meatus, begin voiding, then catch
urine stream
13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40
mg every day. Which of these foods would the nurse reinforce for the
client to eat at least daily? A) spaghetti
B) Watermelon
1. The nurse knows that which statement by the mother indicates that the
mother understands safety precautions with her four month-old infant
and her 4 year-old child?
A) "I strap the infant car seat on the front seat to face backwards."
B) "I place my infant in the middle of the living room floor on a blanket to
play with my
4 year old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks
stuck up in the air
While the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a bottle
in the kitchen
While I make supper."
The correct answer is D: "I have the four year-old hold and help feed
the four month-old a bottle in the kitchen
2. Upon completing the admission documents, the nurse learns that the
87 year-old client does not have an advance directive. What action
should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
The correct answer is B: Give information about advance directives
3. A nurse administers the influenza vaccine to a client in a clinic. Within
15 minutes after
The immunization was given, the client complains of itchy and watery
eyes, increased
Anxiety, and difficulty breathing. The nurse expects that the first action in
the sequence of
Care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
,The correct answer is B: Administer epinephrine 1:1000 as ordered .
4. Which of these children at the site of a disaster at a child day care
center would the triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying
episodes
,B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper
leg fracture
D) A school-age child with singed eyebrows and hair on the arms
The correct answer is B: A toddler with severe deep abrasions over 98%
of the body .
5. When admitting a client to an acute care facility, an identification
bracelet is sent up
With the admission form. In the event these do not match, the nurse’s
best action is to
A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client
The correct answer is C: notify the admissions office and wait to apply the
bracelet
6. The nurse is having difficulty reading the health care provider's written
order that was written right before the shift change. What action should
be taken?
A) Leave the order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification
The correct answer is D: Call the provider for clarification
7. An adult client is found to be unresponsive on morning rounds. After
checking for
Responsiveness and calling for help, the next action that should be
taken by the nurse is to:
A) Check the carotid pulse
B) Deliver 5 abdominal thrusts
C) Give 2 rescue breaths
D) Open the client's airway
The correct answer is D: open the client''s airway
8. A client has an order for 1000 ml of D5W over an 8 hour period. The
nurse discovers that 800 ml has been infused after 4 hours. What is
the priority nursing action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs
The correct answer is D: Auscultate the lungs
9. Following change-of-shift report on an orthopedic unit, which
client should the nurse see first?
, A) 16 year-old who had an open reduction of a fractured wrist 10 hours
ago
B) 20 year-old in skeletal traction for 2 weeks since a motor cycle
accident C) 72 year-old recovering from surgery after a hip replacement 2
hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning
surgery. The correct answer is C: 72 year-old recovering from surgery
after a hip replacement 2 hours ago
10. A nurse observes a family member administer a rectal suppository by
having the
Client lie on the left side for the administration. The family member
pushed the
Suppository until the finger went up to the second knuckle. After 10
minutes the client
Was told by the family member to turn to the right side and the client
did this. What is the appropriate comment for the nurse to make?
A) Why don’t we now have the client turn back to the left side.
B) That was done correctly. Did you have any problems with the
insertion?
C) Let’s check to see if the suppository is in far enough.
D) Did you feel any stool in the intestinal tract?
The correct answer is B: That was done correctly. Did you have
any problems with the insertion?
11. A client with a diagnosis of Methicillin resistant Staphylococcus aureus
(MRSA) has
Died. Which type of precautions is the appropriate type to use
when performing postmortem care?
A) Airborne precautions
B) Droplet precautions
C) Contact precautions
D) Compromised host precautions
The correct answer is C: contact precautions
12. The nurse is reviewing with a client how to collect a clean catch urine
specimen.
Which sequence is appropriate teaching?
A) Void a little, clean the meatus, then collect specimen
B) Clean the meatus, begin voiding, then catch urine stream
C) Clean the meatus, then urinate into container
D) Void continuously and catch some of the urine
The correct answer is B: clean the meatus, begin voiding, then catch
urine stream
13. The provider orders Lanoxin (digoxin) 0.125 mg PO and furosomide 40
mg every day. Which of these foods would the nurse reinforce for the
client to eat at least daily? A) spaghetti
B) Watermelon
