HESI RN EXIT EXAM
WITH ACTUAL CORRECT QUESTIONS
AND VERIFIED DETAILED
ANSWERS|FREQUENTLY TESTED
QUESTIONS AND
SOLUTIONS|NEWEST|GUARANTEED
PASS 2026/2027
The pathophysiological mechanism is responsible for ascites related to liver failure? (Select all that
apply)
a. Bleeding that results from a decreased production of the body's clotting factors
b. Fluid shifts from intravascular to interstitial area due to decreased serum protein
c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
d. Increased circulating aldosterone levels that increase sodium and water retention
e. Decreased absorption of fatty acids in the duodenum leading to abdominal distention.
b. Fluid shifts from intravascular to interstitial area due to decreased serum protein
c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
d. Increased circulating aldosterone levels that increase sodium and water retention
Rationale: When liver fail production of albumin is reduced. Since albumin is the primary serum protein
creating intravascular osmotic pressure, decreased serum protein allows a fluids shift into the interstitial
space. Pressure increases in the portal circulation © when venous return from the upper GI tract cannot
flow freely into sclerosed liver, which cause a pressure gradient to further Increase fluid shifts into the
abdomen. A failing liver ineffectively inactivates steroidal hormones, such as aldosterone resulting in
sodium and water retention.
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document
this sound? (Please listen to the audio first to select the option that applies)
a. S1 S2
b. S1 S2 S3
c. Murmur
d. Pericardial friction rub.
1|Page
,Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence
created by the heart or valvular defect. B is associate with Heart Failure.
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500
mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml.
How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is
required, round to the nearest tenth.
0.4
0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days.
What assessment is most important for the nurse to complete?
a. Auscultate the client's bowel sounds
b. Observe for edema around the ankles
c. Measure the client's capillary glucose level
d. Count the apical and radial pulses simultaneously
Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes
constipation, so it is most important to Auscultate the client's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of
shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops
breathing, and she asks the nurse to document this in her medical record. What action should the nurse
implement?
Ask the client to discuss "do not resuscitate" with her healthcare provider
Ask the client to discuss "do not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed
diarrhea. The client has a new prescription to change the feeding to half strength. What intervention
should the nurse implement?
a. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
b. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr.
c. Maintain the present feeding until diarrhea subsides and the begin the next new prescription.
d. Withhold any further feeding until clarifying the prescription with healthcare provides.
Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
2|Page
,Rationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as a complication of
enteral tube feeding and can be due to a variety of causes including hyperosmolar formula.
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask?
a. "Is there a history of female baldness in your family?"
b. "Are you under any unusual stress at home or work?"
c. "Do you work with hazardous chemicals?"
d. "Have you noticed any changes in your fingernails?"
Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate intervention by the nurse?
a. Bruises on arms and legs
b. Round and tight abdomen
c. Pitting edema in lower legs
d. Capillary refill of 8 seconds
Capillary refill of 8 seconds
Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds
indicates poor perfusion and requires immediate attention
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form
as a witness. What are the legal implications of the nurse's signature on the client's surgical consent
form? (Select all that apply)
a. The client voluntarily grants permission for the procedure to be done
b. The surgeon has explained to the client why the surgery is necessary.
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
e. After considering alternatives to surgery, the client elects to have the procedure.
a. The client voluntarily grants permission for the procedure to be done
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
3|Page
, Rationale: Inform consent is required for any invasive procedure. The nurse's signature as a witness to
the client's signature on surgical consent indicates that the client voluntary gives consent for the
scheduled procedure. C is competent to give consent, and D and understand the risk and benefits of the
procedure.
Following surgery, a male client with antisocial personality disorder frequently requests that a specific
nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the
charge nurse implement?
a. Ask the client to explain why he constantly request the nurse
b. Encourage the client to verbalize his feelings about the nurse
c. Reassure the client that his request will be met whenever possible.
d. Advise the client that assignments are not based on client requests
Advise the client that assignments are not based on clients requests
Rationale: Those with antisocial personality disorders are manipulative in order to meet their own
needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional
maturity prevent effective therapeutic communication and (A and B) will be used to the client's
advantage. C encourage further manipulative behavior.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant.
While providing care, the nurse finds the radiation implant in the bed. What action should the nurse
take?
a. Call the radiology department
b. Reinsert the implant into the vagina
c. Apply double gloves to retrieve the implant for disposal.
d. Place the implant in a lead container using long-handled forceps
Place the implant in a lead container using long-handled forceps
Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are
inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent
tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should
be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then
placed in the lead container.
The client with which type of wound is most likely to need immediate intervention by the nurse?
a. Laceration
b. Abrasion
c. Contusion
d. Ulceration
Laceration
4|Page
WITH ACTUAL CORRECT QUESTIONS
AND VERIFIED DETAILED
ANSWERS|FREQUENTLY TESTED
QUESTIONS AND
SOLUTIONS|NEWEST|GUARANTEED
PASS 2026/2027
The pathophysiological mechanism is responsible for ascites related to liver failure? (Select all that
apply)
a. Bleeding that results from a decreased production of the body's clotting factors
b. Fluid shifts from intravascular to interstitial area due to decreased serum protein
c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
d. Increased circulating aldosterone levels that increase sodium and water retention
e. Decreased absorption of fatty acids in the duodenum leading to abdominal distention.
b. Fluid shifts from intravascular to interstitial area due to decreased serum protein
c. Increased hydrostatic pressure in portal circulation increases fluid shifts into abdomen
d. Increased circulating aldosterone levels that increase sodium and water retention
Rationale: When liver fail production of albumin is reduced. Since albumin is the primary serum protein
creating intravascular osmotic pressure, decreased serum protein allows a fluids shift into the interstitial
space. Pressure increases in the portal circulation © when venous return from the upper GI tract cannot
flow freely into sclerosed liver, which cause a pressure gradient to further Increase fluid shifts into the
abdomen. A failing liver ineffectively inactivates steroidal hormones, such as aldosterone resulting in
sodium and water retention.
The nurse is auscultating a client's heart sounds. Which description should the nurse use to document
this sound? (Please listen to the audio first to select the option that applies)
a. S1 S2
b. S1 S2 S3
c. Murmur
d. Pericardial friction rub.
1|Page
,Murmur
Rationale: A murmur is auscultated as a swishing sound that is associated with the blood turbulence
created by the heart or valvular defect. B is associate with Heart Failure.
The healthcare provider prescribes celtazidime (Fortax) 35 mg every 8 hours IM for an infant. The 500
mg vial is labeled with the instruction to add 5.3 ml diluent to provide a concentration of 100 mg/ml.
How many ml should the nurse administered for each dose? (Enter numeric value only. If rounding is
required, round to the nearest tenth.
0.4
0.4
rationale: 35mg/100mg x 1 = 0.35 = 0.4 ml
The nurse notes that a client has been receiving hydromorphone (Dilaudid) every six hours for four days.
What assessment is most important for the nurse to complete?
a. Auscultate the client's bowel sounds
b. Observe for edema around the ankles
c. Measure the client's capillary glucose level
d. Count the apical and radial pulses simultaneously
Auscultate the client's bowel sounds
Rationale: hydromorphone is a potent opioid analgesic that slows peristalsis and frequently causes
constipation, so it is most important to Auscultate the client's bowel sounds
A female client is admitted with end stage pulmonary disease is alert, oriented, and complaining of
shortness of breath. The client tells the nurse that she wants "no heroic measures" taken if she stops
breathing, and she asks the nurse to document this in her medical record. What action should the nurse
implement?
Ask the client to discuss "do not resuscitate" with her healthcare provider
Ask the client to discuss "do not resuscitate" with her healthcare provider
A client is receiving a full strength continuous enteral tube feeding at 50 ml/hour and has developed
diarrhea. The client has a new prescription to change the feeding to half strength. What intervention
should the nurse implement?
a. Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
b. Continue the full strength feeding after decreasing the rate of infusion to 25 ml/hr.
c. Maintain the present feeding until diarrhea subsides and the begin the next new prescription.
d. Withhold any further feeding until clarifying the prescription with healthcare provides.
Add equal amounts of water and feeding to a feeding bag and infuse at 50ml/hour
2|Page
,Rationale: Diluting the formula can help alleviate the diarrhea. Diarrhea can occur as a complication of
enteral tube feeding and can be due to a variety of causes including hyperosmolar formula.
A female client reports that her hair is becoming coarse and breaking off, that the outer part of her
eyebrows have disappeared, and that her eyes are all puffy. Which follow-up question is best for the
nurse to ask?
a. "Is there a history of female baldness in your family?"
b. "Are you under any unusual stress at home or work?"
c. "Do you work with hazardous chemicals?"
d. "Have you noticed any changes in your fingernails?"
Have you noticed any changes in your fingernails?
Rationale: The pattern of reported manifestations is suggestive of hypothyroidism
After a third hospitalization 6 months ago, a client is admitted to the hospital with ascites and
malnutrition. The client is drowsy but responding to verbal stimuli and reports recently spitting up
blood. What assessment finding warrants immediate intervention by the nurse?
a. Bruises on arms and legs
b. Round and tight abdomen
c. Pitting edema in lower legs
d. Capillary refill of 8 seconds
Capillary refill of 8 seconds
Rationale: The client is bleeding and hypovolemia is likely. Capillary refill is greater than 3 to 5 seconds
indicates poor perfusion and requires immediate attention
After the nurse witnesses a preoperative client sign the surgical consent form, the nurse signs the form
as a witness. What are the legal implications of the nurse's signature on the client's surgical consent
form? (Select all that apply)
a. The client voluntarily grants permission for the procedure to be done
b. The surgeon has explained to the client why the surgery is necessary.
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
e. After considering alternatives to surgery, the client elects to have the procedure.
a. The client voluntarily grants permission for the procedure to be done
c. The client is competent to sign the consent without impairment of judgment
d. The client understands the risks and benefits associated with the procedure
3|Page
, Rationale: Inform consent is required for any invasive procedure. The nurse's signature as a witness to
the client's signature on surgical consent indicates that the client voluntary gives consent for the
scheduled procedure. C is competent to give consent, and D and understand the risk and benefits of the
procedure.
Following surgery, a male client with antisocial personality disorder frequently requests that a specific
nurse be assigned to his care and is belligerent when another nurse is assigned. What action should the
charge nurse implement?
a. Ask the client to explain why he constantly request the nurse
b. Encourage the client to verbalize his feelings about the nurse
c. Reassure the client that his request will be met whenever possible.
d. Advise the client that assignments are not based on client requests
Advise the client that assignments are not based on clients requests
Rationale: Those with antisocial personality disorders are manipulative in order to meet their own
needs. The charge nurse must set limits on this behavior. The client's superficial charm and emotional
maturity prevent effective therapeutic communication and (A and B) will be used to the client's
advantage. C encourage further manipulative behavior.
A client with cervical cancer is hospitalized for insertion of a sealed internal cervical radiation implant.
While providing care, the nurse finds the radiation implant in the bed. What action should the nurse
take?
a. Call the radiology department
b. Reinsert the implant into the vagina
c. Apply double gloves to retrieve the implant for disposal.
d. Place the implant in a lead container using long-handled forceps
Place the implant in a lead container using long-handled forceps
Rationale: Solid or sealed radiation sources, such as Cesium which is removed after treatment, are
inserted into an applicator or cervical implant to emit continuous, low energy radiation for adjacent
tumor tissues. If the radiation source or the applicator become dislodged long-handled forceps should
be used to retrieve the radiation implant to prevent injury due to direct handling. The applicator is then
placed in the lead container.
The client with which type of wound is most likely to need immediate intervention by the nurse?
a. Laceration
b. Abrasion
c. Contusion
d. Ulceration
Laceration
4|Page
