RN HESI FUNDAMENTALS EXIT FINAL
EXAM PREP 2026/2027 QUESTIONS AND
ANSWERS
1. A nurse is caring for a client who is post-operative and experiencing abdominal distension.
Which nursing intervention should be prioritized to promote peristalsis?
A. Encouraging the client to ambulate in the hallway
B. Administering an opioid analgesic for pain
C. Increasing the rate of intravenous fluids
D. Maintaining the client in a supine position
Answer: A
Conceptual Explanation: Ambulation is the most effective nursing intervention to
stimulate peristalsis and alleviate postoperative gas pain or distension. Opioids (A) actually
slow peristalsis. Fluids (C) and positioning (D) are less effective for gas motility.
2. When assessing a client with a localized inflammatory response, which of the following
systemic manifestations should the nurse identify as a priority to report?
A. Redness and warmth at the site
B. Swelling and edema of the affected area
,C. Oral temperature of 101.5°F (38.6°C)
D. Pain rated as 4 on a scale of 0 to 10
Answer: C
Conceptual Explanation: While redness, swelling, and pain are localized signs of
inflammation, a high fever indicates a systemic response or potential sepsis, which requires
immediate reporting and intervention.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which site
is the safest and most recommended for large volume injections?
A. Dorsogluteal
B. Vastus lateralis
C. Deltoid
D. Ventrogluteal
Answer: D
Conceptual Explanation: The ventrogluteal site is considered the safest for adults because
it is deep and away from major blood vessels and nerves. The dorsogluteal (A) is no longer
recommended due to proximity to the sciatic nerve.
4. The nurse is implementing standard precautions for a client. Which action best
demonstrates the application of these precautions?
A. Wearing a gown and gloves for all client contact
, B. Placing the client in a private, negative-pressure room
C. Performing hand hygiene before and after client contact
D. Wearing an N95 respirator during routine vitals
Answer: C
Conceptual Explanation: Hand hygiene is the cornerstone of standard precautions and
must be performed regardless of whether gloves are worn. Gowns (A) are part of contact
precautions. Negative pressure (C) and N95 (D) are for airborne precautions.
5. A nurse finds a client lying on the floor. After ensuring the client is safe and assessing for
injuries, what is the nurse’s next legal responsibility?
A. Document the fall in the client’s medical record, omitting the incident report
B. Complete an incident report and place a copy in the client’s chart
C. Notify the provider and document the facts of the event in the medical record
D. File a report with the state board of nursing immediately
Answer: C
Conceptual Explanation: The nurse must notify the provider and document a factual
account of the fall in the record. Incident reports are internal quality tools and should never
be mentioned or placed in the client’s medical record to maintain legal privilege.
6. Which assessment finding indicates that a client is experiencing a late sign of hypoxia?
A. Restlessness and anxiety
EXAM PREP 2026/2027 QUESTIONS AND
ANSWERS
1. A nurse is caring for a client who is post-operative and experiencing abdominal distension.
Which nursing intervention should be prioritized to promote peristalsis?
A. Encouraging the client to ambulate in the hallway
B. Administering an opioid analgesic for pain
C. Increasing the rate of intravenous fluids
D. Maintaining the client in a supine position
Answer: A
Conceptual Explanation: Ambulation is the most effective nursing intervention to
stimulate peristalsis and alleviate postoperative gas pain or distension. Opioids (A) actually
slow peristalsis. Fluids (C) and positioning (D) are less effective for gas motility.
2. When assessing a client with a localized inflammatory response, which of the following
systemic manifestations should the nurse identify as a priority to report?
A. Redness and warmth at the site
B. Swelling and edema of the affected area
,C. Oral temperature of 101.5°F (38.6°C)
D. Pain rated as 4 on a scale of 0 to 10
Answer: C
Conceptual Explanation: While redness, swelling, and pain are localized signs of
inflammation, a high fever indicates a systemic response or potential sepsis, which requires
immediate reporting and intervention.
3. A nurse is preparing to administer an intramuscular injection to an adult client. Which site
is the safest and most recommended for large volume injections?
A. Dorsogluteal
B. Vastus lateralis
C. Deltoid
D. Ventrogluteal
Answer: D
Conceptual Explanation: The ventrogluteal site is considered the safest for adults because
it is deep and away from major blood vessels and nerves. The dorsogluteal (A) is no longer
recommended due to proximity to the sciatic nerve.
4. The nurse is implementing standard precautions for a client. Which action best
demonstrates the application of these precautions?
A. Wearing a gown and gloves for all client contact
, B. Placing the client in a private, negative-pressure room
C. Performing hand hygiene before and after client contact
D. Wearing an N95 respirator during routine vitals
Answer: C
Conceptual Explanation: Hand hygiene is the cornerstone of standard precautions and
must be performed regardless of whether gloves are worn. Gowns (A) are part of contact
precautions. Negative pressure (C) and N95 (D) are for airborne precautions.
5. A nurse finds a client lying on the floor. After ensuring the client is safe and assessing for
injuries, what is the nurse’s next legal responsibility?
A. Document the fall in the client’s medical record, omitting the incident report
B. Complete an incident report and place a copy in the client’s chart
C. Notify the provider and document the facts of the event in the medical record
D. File a report with the state board of nursing immediately
Answer: C
Conceptual Explanation: The nurse must notify the provider and document a factual
account of the fall in the record. Incident reports are internal quality tools and should never
be mentioned or placed in the client’s medical record to maintain legal privilege.
6. Which assessment finding indicates that a client is experiencing a late sign of hypoxia?
A. Restlessness and anxiety
