HESI RN FUNDAMENTALS EXIT EXAM
Structured Practice Questions, Four-Choice Answers, Correct
Answers, and Rationales
,Clinical Focus: The nurse is called to the waiting room of a pediatric clinic. The frantic
mother states
1. 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. B, C, D
B. A, B, C
C. A, B, D
D. A, C, D
Correct Answer: A. 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.
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Clinical Focus: Which fluid will the nurse select to administer with the prescribed blood
transfusion
2. 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.
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Clinical Focus: When assisting a client from the bed to a chair, which procedure is best for
the
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
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.
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──────
Clinical Focus: How many mL will the nurse document on the client's intake and output
record from the
4. How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
A. 2155 mL
B. 2035 mL
C. 1915 mL
D. 2275 mL
Correct Answer: A. 2155 mL
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
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──────
Clinical Focus: The nurse observes a UAP taking a client's blood pressure in the lower
extremity. Which observation
5. 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.
, ────────────────────────────────────────────────────────────────
──────
Clinical Focus: During a clinic visit, the mother of a 7-year-old reports to the nurse that her
child
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 fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot
determine option C.
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──────
Clinical Focus: The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree)
7. The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
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──────
Clinical Focus: The nurse assesses a 2-year-old who is admitted for dehydration and finds
that the peripheral IV
Structured Practice Questions, Four-Choice Answers, Correct
Answers, and Rationales
,Clinical Focus: The nurse is called to the waiting room of a pediatric clinic. The frantic
mother states
1. 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. B, C, D
B. A, B, C
C. A, B, D
D. A, C, D
Correct Answer: A. 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.
────────────────────────────────────────────────────────────────
──────
Clinical Focus: Which fluid will the nurse select to administer with the prescribed blood
transfusion
2. 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.
────────────────────────────────────────────────────────────────
──────
Clinical Focus: When assisting a client from the bed to a chair, which procedure is best for
the
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
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.
────────────────────────────────────────────────────────────────
──────
Clinical Focus: How many mL will the nurse document on the client's intake and output
record from the
4. How many mL will the nurse document on the client's intake and output record from the
items listed? _____ mL
A. 2155 mL
B. 2035 mL
C. 1915 mL
D. 2275 mL
Correct Answer: A. 2155 mL
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
────────────────────────────────────────────────────────────────
──────
Clinical Focus: The nurse observes a UAP taking a client's blood pressure in the lower
extremity. Which observation
5. 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.
, ────────────────────────────────────────────────────────────────
──────
Clinical Focus: During a clinic visit, the mother of a 7-year-old reports to the nurse that her
child
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 fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful data. The nurse cannot
determine option C.
────────────────────────────────────────────────────────────────
──────
Clinical Focus: The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree)
7. The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Correct Answer: B
Rationale: Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. Option A reverses the hypovolemia that initially
accompanies burn trauma but is not related to decreasing the proliferation of infective
organisms. Options C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent infection.
────────────────────────────────────────────────────────────────
──────
Clinical Focus: The nurse assesses a 2-year-old who is admitted for dehydration and finds
that the peripheral IV
