RN HESI EXIT EXAM VERSION 1 V1 2026
EXAM SCRIPT TEST BANK FULL SOLUTION
160 QUESTIONS AND ANSWERS
⩥ During a clinic visit, the mother of a 7-year-old reports to the nurse
that her child is often awake until midnight playing and is then very
difficult to awaken in the morning for school. Which assessment data
should the nurse obtain in response to the mother's concern?
A.
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. Answer: D
Rationale: School-age children often resist bedtime. The nurse should
begin by assessing the environment of the home to determine factors that
may not be conducive to the establishment of bedtime rituals that
promote sleep. Option A often causes daytime fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful data.
The nurse cannot determine option C.
,⩥ The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree) burns. What
action has the highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns. Answer: B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A
reverses the hypovolemia that initially accompanies burn trauma but is
not related to decreasing the proliferation of infective organisms.
Options C and D are recommended by various burn centers as possible
ways to reduce the chance of infection. Option B is a proven technique
to prevent infection.
⩥ The nurse assesses a 2-year-old who is admitted for dehydration and
finds that the peripheral IV rate by gravity has slowed, even though the
venous access site is healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
,Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.. Answer: B
Rationale: The nurse should first check the tubing and height of the bag
on the IV pole, which are common factors that may slow the rate.
Gravity infusion rates are influenced by the height of the bag, tubing
clamp closure or kinks, needle size or position, fluid viscosity, client
blood pressure (crying in the pediatric client), and infiltration.
Venospasm can slow the rate and often responds to warmth over the
vessel, but the nurse should first adjust the IV pole height. The nurse
may need to adjust the stabilizing tape on a positional needle or flush the
venous access with normal saline, but less invasive actions should be
implemented first.
⩥ The nurse manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
, D.
Turn the client from side to back every shift.. Answer: A
Rationale: Performing range-of-motion exercises is beneficial in
reducing contractures around joints. Options B, C, and D are all
potentially harmful practices that place the immobile client at risk of
complications.
⩥ The nurse administered 10 mg of diazepam to the preoperative client.
What steps will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom. Answer: B, C, D
Rationale: Diazepam is a common preoperative medication. Close
observation by placing the client close to the nurse's station is not
necessary. The medication has a sedative effect and the client should not
get out of bed, even with assistance. The remaining selections are
correct.
EXAM SCRIPT TEST BANK FULL SOLUTION
160 QUESTIONS AND ANSWERS
⩥ During a clinic visit, the mother of a 7-year-old reports to the nurse
that her child is often awake until midnight playing and is then very
difficult to awaken in the morning for school. Which assessment data
should the nurse obtain in response to the mother's concern?
A.
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. Answer: D
Rationale: School-age children often resist bedtime. The nurse should
begin by assessing the environment of the home to determine factors that
may not be conducive to the establishment of bedtime rituals that
promote sleep. Option A often causes daytime fatigue rather than
resistance to going to sleep. Option B is unlikely to provide useful data.
The nurse cannot determine option C.
,⩥ The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree) burns. What
action has the highest priority in decreasing the client's risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns. Answer: B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A
reverses the hypovolemia that initially accompanies burn trauma but is
not related to decreasing the proliferation of infective organisms.
Options C and D are recommended by various burn centers as possible
ways to reduce the chance of infection. Option B is a proven technique
to prevent infection.
⩥ The nurse assesses a 2-year-old who is admitted for dehydration and
finds that the peripheral IV rate by gravity has slowed, even though the
venous access site is healthy. What should the nurse do next?
A.
Apply a warm compress proximal to the site.
B.
,Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.. Answer: B
Rationale: The nurse should first check the tubing and height of the bag
on the IV pole, which are common factors that may slow the rate.
Gravity infusion rates are influenced by the height of the bag, tubing
clamp closure or kinks, needle size or position, fluid viscosity, client
blood pressure (crying in the pediatric client), and infiltration.
Venospasm can slow the rate and often responds to warmth over the
vessel, but the nurse should first adjust the IV pole height. The nurse
may need to adjust the stabilizing tape on a positional needle or flush the
venous access with normal saline, but less invasive actions should be
implemented first.
⩥ The nurse manager of a skilled nursing (chronic care) unit is
instructing UAPs on ways to prevent complications of immobility.
Which action should be included in this instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
, D.
Turn the client from side to back every shift.. Answer: A
Rationale: Performing range-of-motion exercises is beneficial in
reducing contractures around joints. Options B, C, and D are all
potentially harmful practices that place the immobile client at risk of
complications.
⩥ The nurse administered 10 mg of diazepam to the preoperative client.
What steps will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom. Answer: B, C, D
Rationale: Diazepam is a common preoperative medication. Close
observation by placing the client close to the nurse's station is not
necessary. The medication has a sedative effect and the client should not
get out of bed, even with assistance. The remaining selections are
correct.
