HESI Exit v2 latest update 2025/2026
The nurse knows which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4year-old
child?
A) "I strap the infant car seat on the front seat to face backwards." B) "I place my
infant in the middle of the living room floor on a blanket to play with my 4 year
old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in the
air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old bottle in the
kitchen
while I make supper." - ANSWER-The correct answer is D: "I have the four year-old
hold and help feed the four month-old a bottle in the kitchen
Upon completing the admission documents, the nurse learns that the 87 year-old
client does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
,D) Refer this issue to the unit secretary; - ANSWER-The correct answer is B: Give
information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes
after the immunization was given, the client complains of itchy and watery eyes,
increased anxiety, and difficulty breathing. The nurse expects that the first action
in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered - ANSWER-The correct answer is B:
Administer epinephrine 1:1000 as ordered .
Which of these children at the site of a disaster at a child day care center would
thea triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg
fracture
D) A school-age child with singed eyebrows and hair on the arms - ANSWER-The
correct answer is B: A toddler with severe deep abrasions over 98% of the body .
When admitting a client to an acute care facility, an identification bracelet is sent
up with the admission form. In the event these do not match, the nurse's best
action is to
,A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client - ANSWER-The correct
answer is C: notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's writtenorder that
was
written right before the shift change. What action should be taken? A) Leave the
order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification - ANSWER-The correct answer is D: Call the
provider for clarification
An adult client is found to be unresponsive on morning rounds. After Checking for
responsiveness and calling for help, the next action that should be taken by the
nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway - ANSWER-The correct answer is D: open the client''s
airway
, A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discovers that 800 ml has been infused after 4 hours. What is the priority nursing
action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs - ANSWER-The correct answer is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the
nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery. -
ANSWER-The correct answer is C: 72 year-old recovering from surgery after hip
replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the
client lie on the left side for the administration. The family member pushed the
suppository until the finger went up to the second knuckle. After 10 minutes the
client
was told by the family member to turn to the right side and the client did this.
What is the
appropriate comment for the nurse to make?
A) Why don't we now have the client turn back to the left side.
The nurse knows which statement by the mother indicates that the mother
understands safety precautions with her four month-old infant and her 4year-old
child?
A) "I strap the infant car seat on the front seat to face backwards." B) "I place my
infant in the middle of the living room floor on a blanket to play with my 4 year
old while I make supper in the kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocksstuck up in the
air
while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old bottle in the
kitchen
while I make supper." - ANSWER-The correct answer is D: "I have the four year-old
hold and help feed the four month-old a bottle in the kitchen
Upon completing the admission documents, the nurse learns that the 87 year-old
client does not have an advance directive. What action should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
,D) Refer this issue to the unit secretary; - ANSWER-The correct answer is B: Give
information about advance directives
A nurse administers the influenza vaccine to a client in a clinic. Within 15 minutes
after the immunization was given, the client complains of itchy and watery eyes,
increased anxiety, and difficulty breathing. The nurse expects that the first action
in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered - ANSWER-The correct answer is B:
Administer epinephrine 1:1000 as ordered .
Which of these children at the site of a disaster at a child day care center would
thea triage nurse put in the "treat last" category?
A) An infant with intermittent bulging anterior fontanel between crying episodes
B) A toddler with severe deep abrasions over 98% of the body
C) A preschooler with 1 lower leg fracture and the other leg with an upper leg
fracture
D) A school-age child with singed eyebrows and hair on the arms - ANSWER-The
correct answer is B: A toddler with severe deep abrasions over 98% of the body .
When admitting a client to an acute care facility, an identification bracelet is sent
up with the admission form. In the event these do not match, the nurse's best
action is to
,A) Change whichever item is incorrect to the correct information
B) Use the bracelet and admission form until a replacement is supplied
C) Notify the admissions office and wait to apply the bracelet
D) Make a corrected identification bracelet for the client - ANSWER-The correct
answer is C: notify the admissions office and wait to apply the bracelet
The nurse is having difficulty reading the health care provider's writtenorder that
was
written right before the shift change. What action should be taken? A) Leave the
order for the oncoming staff to follow-up
B) Contact the charge nurse for an interpretation
C) Ask the pharmacy for assistance in the interpretation
D) Call the provider for clarification - ANSWER-The correct answer is D: Call the
provider for clarification
An adult client is found to be unresponsive on morning rounds. After Checking for
responsiveness and calling for help, the next action that should be taken by the
nurse is to:
A) check the carotid pulse
B) deliver 5 abdominal thrusts
C) give 2 rescue breaths
D) open the client's airway - ANSWER-The correct answer is D: open the client''s
airway
, A client has an order for 1000 ml of D5W over an 8 hour period. The nurse
discovers that 800 ml has been infused after 4 hours. What is the priority nursing
action?
A) Ask the client if there are any breathing problems
B) Have the client void as much as possible
C) Check the vital signs
D) Auscultate the lungs - ANSWER-The correct answer is D: Auscultate the lungs
Following change-of-shift report on an orthopedic unit, which client should the
nurse
see first?
A) 16 year-old who had an open reduction of a fractured wrist 10 hours ago
B) 20 year-old in skeletal traction for 2 weeks since a motorcycle accident
C) 72 year-old recovering from surgery after a hip replacement 2 hours ago
D) 75 year-old who is in skin traction prior to planned hip pinning surgery. -
ANSWER-The correct answer is C: 72 year-old recovering from surgery after hip
replacement 2 hours ago
A nurse observes a family member administer a rectal suppository by having the
client lie on the left side for the administration. The family member pushed the
suppository until the finger went up to the second knuckle. After 10 minutes the
client
was told by the family member to turn to the right side and the client did this.
What is the
appropriate comment for the nurse to make?
A) Why don't we now have the client turn back to the left side.
