Western Governors University D 440
HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2025-2026 ACTUAL EXAM 100
QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED ANSWERS)
The nurse is called to the waiting room of a pediatric B, C, D
clinic. The frantic mother states, "I think my 4-month-old Rationale: The fingers are placed at the same location on an
infant as chest baby is choking!" What steps will the nurse take? (Select compressions for CPR; however, the nurse
must deliver five chest thrusts, after all that apply.) the five back slaps. Blind sweeps are not used as this action may
push the
A. object deeper into the throat. The remaining steps are correct.
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.
1/
35
,Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible
with
A. blood.
5% Dextrose and
water B.
Normal
saline C.
Lactated Ringers
solution D.
5% Dextrose and lactated ringers
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and
affords
A. the nurse a wide base of support while stabilizing the client's
knees when Place the chair parallel to the bed, with its back toward assisting to a standing position. The
chair should be placed at a 45-degree
the head of the bed and assist the client in moving to angle to the bed, with the back of the chair toward the head
of the bed. Clients the chair. should never be lifted under the axillae; this could damage nerves
and strain
B. the nurse's back. The client should be instructed to use the arms of
the chair With the nurse's feet spread apart and knees aligned and should never place his or her arms around
the nurse's neck; this places with the client's knees, stand and pivot the client into undue stress on the nurse's neck
and back and increases the risk for a fall. 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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of
gelatin 8 ounces of
orange juice
355 mL can of soda1 cup of soup
2/
35
,The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation of Rationale: When obtaining the blood pressure in the lower
extremities, the this procedure requires the nurse to intervene with the popliteal pulse is the site for auscultation
when the blood pressure cuff is UAP's approach? applied around the thigh. The nurse should intervene with the
UAP who has
A. applied the cuff on the lower leg. Option A ensures an accurate
assessment, The cuff wraps around the girth of the leg. and option C provides the best access to the artery. Systolic
pressure in the
B. popliteal artery is usually 10 to 40 mm Hg higher than in the brachial
artery.
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.
During a clinic visit, the mother of a 7-year-old reports D
to the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse
should begin by playing and is then very difficult to awaken in the assessing the environment of the home to
determine factors that may not be
morning for school. Which assessment data should the conducive to the establishment of bedtime rituals that
promote sleep. Option A nurse obtain in response to the mother's concern? often causes daytime fatigue rather
than resistance to going to sleep. Option B
A. is unlikely to provide useful data. The nurse cannot
determine option C. 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
The nurse identifies a potential for infection in a clientB
with partial-thickness (second-degree) and full- Rationale: Careful handwashing technique is the single most
effective thickness (third-degree) burns. What action has the intervention for the prevention of contamination to
all clients. Option A highest priority in decreasing the client's risk of reverses the hypovolemia that initially
accompanies burn trauma but is not infection? related to decreasing the proliferation of infective organisms.
Options C and D
A. are recommended by various burn centers as possible ways to
reduce the Administration of plasma expanders chance of infection. Option B is a proven technique to prevent
infection. B.
Use of careful handwashing
technique C.
Application of a topical antibacterial
cream D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by Rationale: The nurse should first check the tubing and height of the
bag on the gravity has slowed, even though the venous access site IV pole, which are common factors that may slow the
rate. Gravity infusion rates is healthy. What should the nurse do next? are influenced by the height of the bag,
tubing clamp closure or kinks, needle
A. size or position, fluid viscosity, client blood pressure (crying in
the pediatric Apply a warm compress proximal to the site. client), and infiltration. Venospasm can slow the rate and
often responds to
B. warmth over the vessel, but the nurse should first adjust the IV pole
height. The Check for kinks in the tubing and raise the IV pole. nurse may need to adjust the stabilizing tape on a
positional needle or flush the
C. venous access with normal saline, but less invasive actions should be
3/
35
, Adjust the tape that stabilizes the needle. implemented
first. D.
Flush with normal saline and recount the drop rate.
4/
35
HESI RN FUNDAMENTALS EXIT EXAM
LATEST 2025-2026 ACTUAL EXAM 100
QUESTIONS AND CORRECT ANSWERS
WITH RATIOANLES (VERIFIED ANSWERS)
The nurse is called to the waiting room of a pediatric B, C, D
clinic. The frantic mother states, "I think my 4-month-old Rationale: The fingers are placed at the same location on an
infant as chest baby is choking!" What steps will the nurse take? (Select compressions for CPR; however, the nurse
must deliver five chest thrusts, after all that apply.) the five back slaps. Blind sweeps are not used as this action may
push the
A. object deeper into the throat. The remaining steps are correct.
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.
1/
35
,Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible
with
A. blood.
5% Dextrose and
water B.
Normal
saline C.
Lactated Ringers
solution D.
5% Dextrose and lactated ringers
When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and
affords
A. the nurse a wide base of support while stabilizing the client's
knees when Place the chair parallel to the bed, with its back toward assisting to a standing position. The
chair should be placed at a 45-degree
the head of the bed and assist the client in moving to angle to the bed, with the back of the chair toward the head
of the bed. Clients the chair. should never be lifted under the axillae; this could damage nerves
and strain
B. the nurse's back. The client should be instructed to use the arms of
the chair With the nurse's feet spread apart and knees aligned and should never place his or her arms around
the nurse's neck; this places with the client's knees, stand and pivot the client into undue stress on the nurse's neck
and back and increases the risk for a fall. 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.
How many mL will the nurse document on the client's Answer: 2155
intake and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of
gelatin 8 ounces of
orange juice
355 mL can of soda1 cup of soup
2/
35
,The nurse observes a UAP taking a client's blood B
pressure in the lower extremity. Which observation of Rationale: When obtaining the blood pressure in the lower
extremities, the this procedure requires the nurse to intervene with the popliteal pulse is the site for auscultation
when the blood pressure cuff is UAP's approach? applied around the thigh. The nurse should intervene with the
UAP who has
A. applied the cuff on the lower leg. Option A ensures an accurate
assessment, The cuff wraps around the girth of the leg. and option C provides the best access to the artery. Systolic
pressure in the
B. popliteal artery is usually 10 to 40 mm Hg higher than in the brachial
artery.
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.
During a clinic visit, the mother of a 7-year-old reports D
to the nurse that her child is often awake until midnight Rationale: School-age children often resist bedtime. The nurse
should begin by playing and is then very difficult to awaken in the assessing the environment of the home to
determine factors that may not be
morning for school. Which assessment data should the conducive to the establishment of bedtime rituals that
promote sleep. Option A nurse obtain in response to the mother's concern? often causes daytime fatigue rather
than resistance to going to sleep. Option B
A. is unlikely to provide useful data. The nurse cannot
determine option C. 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
The nurse identifies a potential for infection in a clientB
with partial-thickness (second-degree) and full- Rationale: Careful handwashing technique is the single most
effective thickness (third-degree) burns. What action has the intervention for the prevention of contamination to
all clients. Option A highest priority in decreasing the client's risk of reverses the hypovolemia that initially
accompanies burn trauma but is not infection? related to decreasing the proliferation of infective organisms.
Options C and D
A. are recommended by various burn centers as possible ways to
reduce the Administration of plasma expanders chance of infection. Option B is a proven technique to prevent
infection. B.
Use of careful handwashing
technique C.
Application of a topical antibacterial
cream D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by Rationale: The nurse should first check the tubing and height of the
bag on the gravity has slowed, even though the venous access site IV pole, which are common factors that may slow the
rate. Gravity infusion rates is healthy. What should the nurse do next? are influenced by the height of the bag,
tubing clamp closure or kinks, needle
A. size or position, fluid viscosity, client blood pressure (crying in
the pediatric Apply a warm compress proximal to the site. client), and infiltration. Venospasm can slow the rate and
often responds to
B. warmth over the vessel, but the nurse should first adjust the IV pole
height. The Check for kinks in the tubing and raise the IV pole. nurse may need to adjust the stabilizing tape on a
positional needle or flush the
C. venous access with normal saline, but less invasive actions should be
3/
35
, Adjust the tape that stabilizes the needle. implemented
first. D.
Flush with normal saline and recount the drop rate.
4/
35
