HESI RN FUNDAMENTALS EXIT EXAM |ACTUAL
QUESTIONS & VERIFIED ANSWERS 2026-2027
UPDATED EDITION |GRADED A+
Question 1
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
CORRECT ANSWER
B
Rationale: Normal saline solution is the only solution that is compatible with blood.
Question 2
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.
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@THE STUDY VAULT
,Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
CORRECT ANSWER
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.
Question 3
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.
CORRECT ANSWER
B
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@THE STUDY VAULT
,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.
Question 4
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.
CORRECT ANSWER
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.
Question 5
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@THE STUDY VAULT
, 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
CORRECT ANSWER
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
Question 6
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
CORRECT ANSWER
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 conducive to the
establishment of bedtime rituals that promote sleep. Option A often causes daytime
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@THE STUDY VAULT
QUESTIONS & VERIFIED ANSWERS 2026-2027
UPDATED EDITION |GRADED A+
Question 1
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
CORRECT ANSWER
B
Rationale: Normal saline solution is the only solution that is compatible with blood.
Question 2
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.
1
@THE STUDY VAULT
,Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
CORRECT ANSWER
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.
Question 3
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.
CORRECT ANSWER
B
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@THE STUDY VAULT
,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.
Question 4
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.
CORRECT ANSWER
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.
Question 5
3
@THE STUDY VAULT
, 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
CORRECT ANSWER
Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
Question 6
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
CORRECT ANSWER
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 conducive to the
establishment of bedtime rituals that promote sleep. Option A often causes daytime
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@THE STUDY VAULT
