ULTIMATE HESI RN EXIT EXAM TEST BANK 2025–2026:
EXAM-FOCUSED QUESTIONS, DETAILED EXPLANATIONS &
A+ SUCCESS;
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will
cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers. - ANSWER--D
Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to
neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these
clients. The remaining options pose a low risk for infection.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert.
Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
Assist the client in extending the neck back so the tube may enter the larynx. - ANSWER--A, D
Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Placement of an
NG tube can be uncomfortable and can induce gagging. The tube should be measured from the tip of
the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should
1|Page
,only be extended back prior to the tube passing the pharynx and then the client should be instructed
to position the neck forward (E).
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days.
She states, "I have been told that it is harmful to bathe during my period." Which action should the
nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area.
C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with the client. - ANSWER--D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should
receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client
teaching, the client may still choose option A or B. Brochures reinforce the teaching.
The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I
know your children want to come over and say goodbye before we call the funeral home. Just let me
know when you are ready for me to prepare the body." What steps will the nurse include in the
postmortem care? (Select all that apply.)
A.
Remove the existing Foley catheter.
B.
Wash the genitalia only.
C.
Close the client's eyes.
D.
Remove soiled padding under the client.
E.
Place a dressing over the abdominal scar. - ANSWER--A, C, D
Rationale: Postmortem care includes making the client ready for the family to view prior to the
client's transfer to the mortuary. The nurse need to make sure the client's body is completely
2|Page
,washed, and all dressings and all tubes, i.e. Foley, NG, IV, are removed. As the client may excrete
contents from the bowel and the bladder during the dying process, remove all soiled pads and
bedding from under the client and replace with fresh items. Make sure the client's eyes are closed.
A hospitalized client has had difficulty falling asleep for two nights, and is becoming irritable and
restless. Which action by the nurse is best?
A.
Determine the client's usual bedtime routine and include these rituals in the plan of care as safety
allows.
B.
Instruct the UAP not to wake the client under any circumstances during the night.
C.
Place a "Do Not Disturb" sign on the door and change assessments from every 4 to 8 hours.
D.
Encourage the client to avoid pain medication during the day, which might increase daytime napping.
- ANSWER--A
Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow
the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the
client's standard of care and compromise safety.
Which instruction is most important for the nurse to include when teaching a client with limited
mobility strategies to prevent venous thrombosis?
A.
Perform cough and deep breathing exercises hourly.
B.
Turn from side to side in bed at least every 2 hours.
C.
Dorsiflex and plantarflex the feet 10 times each hour.
D.
Drink approximately 4 ounces of water every hour. - ANSWER--C
Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures
that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful
to prevent other complications of immobility but are less effective in preventing venous thrombus
formation than option C.
3|Page
, For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to
the client? (Select all that apply.)
A.
Bacon, egg, and cheese biscuit
B.
Chinese chicken and vegetables, with rice and soy sauce
C.
Strawberry, spinach salad with yogurt-based blue cheese dressing
D.
Chicken salad stuffed fresh tomato with a side of celery sticks
E.
Grilled tilapia with a fresh green side salad
F.
Grilled hot dog on a bun with ketchup and mustard - ANSWER--A, B, F
Rationale: The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and
vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in
sodium.
A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of
respiratory compromise for this client. What will the nurse include in this client's plan of care?
(Select all that apply.)
A.
Raise the head of the bed to no less than a 45 degrees angle.
B.
Have the client use an incentive spirometer 10 times every hour while awake.
C.
Limit total fluid intake to no more than 1000 mL/day.
D.
Have the client sit on the side of the bed instead of getting up and walking.
E.
Ask the client to take deep breaths and cough five times every hour while awake. - ANSWER--A, B, E
Rationale:As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep
the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting
4|Page
EXAM-FOCUSED QUESTIONS, DETAILED EXPLANATIONS &
A+ SUCCESS;
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will
cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers. - ANSWER--D
Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to
neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these
clients. The remaining options pose a low risk for infection.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert.
Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
Assist the client in extending the neck back so the tube may enter the larynx. - ANSWER--A, D
Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Placement of an
NG tube can be uncomfortable and can induce gagging. The tube should be measured from the tip of
the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should
1|Page
,only be extended back prior to the tube passing the pharynx and then the client should be instructed
to position the neck forward (E).
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days.
She states, "I have been told that it is harmful to bathe during my period." Which action should the
nurse take first?
A.
Accept and document the client's wish to refrain from bathing.
B.
Offer to give the client a bed bath, avoiding the perineal area.
C.
Obtain written brochures about menstruation to give to the client.
D.
Teach the importance of personal hygiene during menstruation with the client. - ANSWER--D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should
receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client
teaching, the client may still choose option A or B. Brochures reinforce the teaching.
The spouse is at the bedside of the client who just died. The hospice nurse states to the spouse, "I
know your children want to come over and say goodbye before we call the funeral home. Just let me
know when you are ready for me to prepare the body." What steps will the nurse include in the
postmortem care? (Select all that apply.)
A.
Remove the existing Foley catheter.
B.
Wash the genitalia only.
C.
Close the client's eyes.
D.
Remove soiled padding under the client.
E.
Place a dressing over the abdominal scar. - ANSWER--A, C, D
Rationale: Postmortem care includes making the client ready for the family to view prior to the
client's transfer to the mortuary. The nurse need to make sure the client's body is completely
2|Page
,washed, and all dressings and all tubes, i.e. Foley, NG, IV, are removed. As the client may excrete
contents from the bowel and the bladder during the dying process, remove all soiled pads and
bedding from under the client and replace with fresh items. Make sure the client's eyes are closed.
A hospitalized client has had difficulty falling asleep for two nights, and is becoming irritable and
restless. Which action by the nurse is best?
A.
Determine the client's usual bedtime routine and include these rituals in the plan of care as safety
allows.
B.
Instruct the UAP not to wake the client under any circumstances during the night.
C.
Place a "Do Not Disturb" sign on the door and change assessments from every 4 to 8 hours.
D.
Encourage the client to avoid pain medication during the day, which might increase daytime napping.
- ANSWER--A
Rationale: Including habitual rituals that do not interfere with the client's care or safety may allow
the client to go to sleep faster and increase the quality of care. Options B, C, and D decrease the
client's standard of care and compromise safety.
Which instruction is most important for the nurse to include when teaching a client with limited
mobility strategies to prevent venous thrombosis?
A.
Perform cough and deep breathing exercises hourly.
B.
Turn from side to side in bed at least every 2 hours.
C.
Dorsiflex and plantarflex the feet 10 times each hour.
D.
Drink approximately 4 ounces of water every hour. - ANSWER--C
Rationale: To reduce the risk of venous thrombosis, the nurse should instruct the client in measures
that promote venous return, such as dorsiflexion and plantar flexion. Options A, B, and D are helpful
to prevent other complications of immobility but are less effective in preventing venous thrombus
formation than option C.
3|Page
, For the client with a sodium level of 128 mEq/L, which meal selections should the nurse suggest to
the client? (Select all that apply.)
A.
Bacon, egg, and cheese biscuit
B.
Chinese chicken and vegetables, with rice and soy sauce
C.
Strawberry, spinach salad with yogurt-based blue cheese dressing
D.
Chicken salad stuffed fresh tomato with a side of celery sticks
E.
Grilled tilapia with a fresh green side salad
F.
Grilled hot dog on a bun with ketchup and mustard - ANSWER--A, B, F
Rationale: The client is hyponatremic and additional salt is needed in the diet. Fresh fruits and
vegetables are low in sodium. Bacon, soy, and hot dogs with ketchup and mustard are high in
sodium.
A 76-year-old client has returned from surgery. The nurse plans on decreasing the chance of
respiratory compromise for this client. What will the nurse include in this client's plan of care?
(Select all that apply.)
A.
Raise the head of the bed to no less than a 45 degrees angle.
B.
Have the client use an incentive spirometer 10 times every hour while awake.
C.
Limit total fluid intake to no more than 1000 mL/day.
D.
Have the client sit on the side of the bed instead of getting up and walking.
E.
Ask the client to take deep breaths and cough five times every hour while awake. - ANSWER--A, B, E
Rationale:As long as the client is not on a fluid restriction, offer no less than 2000 mL of fluid to keep
the body well hydrated and keep respiratory secretions loose. Ambulation is key for this client. Sitting
4|Page
