HESI RN FUNDAMENTALS EXIT EXAM 2026
WITH QUESTIONS AND ANSWERS||
GUARANTEED PASS||| ALREADY GRADED A+
A client's blood pressure reading is 156/94 mm Hg. Which action should the
nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be
verified by another nurse.
B. Contact the health care provider to report the reading and obtain a
prescription for an antihypertensive medication.
C. Replace the cuff with a larger one to ensure an ample fit for the client to
increase arm comfort.
D. Compare the current reading with the client's previously documented blood
pressure readings. - ANSWER-D
Rationale: Comparing this reading with previous readings will provide
information about what is normal for this client; this action should be taken
first. Option A might unnecessarily alarm the client. Option B is premature.
Further assessment is needed to determine if the reading is abnormal for this
client. Option C could falsely decrease the reading and is not the correct
procedure for obtaining a blood pressure reading.
The nurse comes upon an automobile accident involving many cars. Which
victim should the nurse see first?
A. The victim who is not breathing and does not have a pulse
B. The victim who is bleeding out of both the ears, and the nose and mouth,
with a blank stare
C. The victim who is heavily bleeding bright red blood from a thigh wound
, D. The victim who is crying, complaining of arm pain, and no other apparent
injuries - ANSWER-C
Rationale: The client hemorrhaging from the leg wound is the priority as of the
severely injured clients; the nurse can help the client by tying off the leg above
the injury and/or applying pressure to the wound site. When there is only one
health care provider on the scene, the nurse must provide care to those who are
most likely to survive. The client without a pulse and respirations is dead. The
client with bleeding from the ears, nose, and mouth, with a blank stare, likely
has severe head trauma. The victim with arm pain and crying is the lowest
priority.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR
was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming
nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV
bag. What is the nurse's next action?
A. Contact the healthcare provider on call.
B. Call in the off going nurse and request an explanation.
C. Tell the client that 950 mL of fluid just accidentally infused.
D. Auscultate the client's lungs. - ANSWER-D
Rationale: The client may show signs of fluid overload, such as crackles. Other
respiratory signs are dyspnea and increased rate. Assess the client's reaction to
the fluid bolus first and then proceed with notifying the charge nurse and the
health care provider.
The health care provider has changed a client's prescription from the PO to the
IV route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication?
A. The client will experience increased tolerance to the drug's effects and may
need a higher dose.
B. The onset of action of the drug will occur more rapidly, resulting in a more
rapid effect.
C. The medication will be more highly protein-bound, increasing the duration
of action.
, D. The therapeutic index will be increased, placing the client at greater risk for
toxicity. - ANSWER-B
Rationale: Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in a
more immediate effect. Drug tolerance, protein binding, and the drug's
therapeutic index are not affected by the change in route from PO to IV. In
addition, an increased therapeutic index reduces the risk of drug toxicity.
Which steps should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back. - ANSWER-A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A
cotton ball should be placed in the outermost canal (D). The auricle is pulled
down and back for a child younger than 3 years of age, but not an adult (E).
The nurse is evaluating measures implemented for the non-responsive client.
Which findings indicate the effectiveness of the care delivered? (Select all that
apply.)
A. Footboard at the end of the bed
B. Heals without redness bilaterally
C. Skin intact on the back
D. Sheepskin booties in place
E. Elbow joint fully flexes and extends.
F. Ankle joint rotates 360 degrees freely. - ANSWER-B, C, E, F
Rationale: The footboard helps prevent foot drop, but does not measure the
effectiveness of the treatment. The sheepskin booties are in place to protect the
, heal, but they do not demonstrate the effectiveness. The remaining are
assessments that demonstrate the interventions are effective.
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months - ANSWER-B
Rationale: Anticoagulants increase the risk for bleeding during surgery, which
can pose a threat for the development of surgical complications. The health care
provider should be informed that the client is taking these drugs. Although
clients who take birth control pills may be more susceptible to the development
of thrombi, such problems usually occur postoperatively. A client with option C
or D is at less of a surgical risk than with option B.
The nurse is evaluating the chart of a client scheduled for surgery in 1 hour.
When viewing the consent form, the nurse notes the surgeon's signature, but not
the client's signature. What steps must the nurse take? (Select all that apply.)
A. Call the surgeon.
B. Ask the client, "Did your surgeon explain the procedure to you?"
C. Have the client's spouse sign the form.
D. Ask the client, "Do you have any questions?"
E. Witness the signature.
F. Obtain the consent. - ANSWER-B, D, E
Rationale:It is the surgeon's responsibility to review the procedure with the
client until the client has no further questions. The nurse can verify the review
by the surgeon and ask if the client has any further questions. If the client has
questions, the nurse must call in the surgeon. When the nurse signs the consent
form, the nurse is witnessing the signature only.
WITH QUESTIONS AND ANSWERS||
GUARANTEED PASS||| ALREADY GRADED A+
A client's blood pressure reading is 156/94 mm Hg. Which action should the
nurse take first?
A. Tell the client that the blood pressure is high and that the reading needs to be
verified by another nurse.
B. Contact the health care provider to report the reading and obtain a
prescription for an antihypertensive medication.
C. Replace the cuff with a larger one to ensure an ample fit for the client to
increase arm comfort.
D. Compare the current reading with the client's previously documented blood
pressure readings. - ANSWER-D
Rationale: Comparing this reading with previous readings will provide
information about what is normal for this client; this action should be taken
first. Option A might unnecessarily alarm the client. Option B is premature.
Further assessment is needed to determine if the reading is abnormal for this
client. Option C could falsely decrease the reading and is not the correct
procedure for obtaining a blood pressure reading.
The nurse comes upon an automobile accident involving many cars. Which
victim should the nurse see first?
A. The victim who is not breathing and does not have a pulse
B. The victim who is bleeding out of both the ears, and the nose and mouth,
with a blank stare
C. The victim who is heavily bleeding bright red blood from a thigh wound
, D. The victim who is crying, complaining of arm pain, and no other apparent
injuries - ANSWER-C
Rationale: The client hemorrhaging from the leg wound is the priority as of the
severely injured clients; the nurse can help the client by tying off the leg above
the injury and/or applying pressure to the wound site. When there is only one
health care provider on the scene, the nurse must provide care to those who are
most likely to survive. The client without a pulse and respirations is dead. The
client with bleeding from the ears, nose, and mouth, with a blank stare, likely
has severe head trauma. The victim with arm pain and crying is the lowest
priority.
At hand-off report the off going nurse reports a new 1000 mL IV bag of D5LR
was hung at 1845. The prescribed infusion rate is 75 mL/hr. The oncoming
nurse assesses the client at 1915 and notes there is less than 50 mL left in the IV
bag. What is the nurse's next action?
A. Contact the healthcare provider on call.
B. Call in the off going nurse and request an explanation.
C. Tell the client that 950 mL of fluid just accidentally infused.
D. Auscultate the client's lungs. - ANSWER-D
Rationale: The client may show signs of fluid overload, such as crackles. Other
respiratory signs are dyspnea and increased rate. Assess the client's reaction to
the fluid bolus first and then proceed with notifying the charge nurse and the
health care provider.
The health care provider has changed a client's prescription from the PO to the
IV route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication?
A. The client will experience increased tolerance to the drug's effects and may
need a higher dose.
B. The onset of action of the drug will occur more rapidly, resulting in a more
rapid effect.
C. The medication will be more highly protein-bound, increasing the duration
of action.
, D. The therapeutic index will be increased, placing the client at greater risk for
toxicity. - ANSWER-B
Rationale: Because the absorptive process is eliminated when medications are
administered via the IV route, the onset of action is more rapid, resulting in a
more immediate effect. Drug tolerance, protein binding, and the drug's
therapeutic index are not affected by the change in route from PO to IV. In
addition, an increased therapeutic index reduces the risk of drug toxicity.
Which steps should the nurse take when administering ear drops to an adult
client? (Select all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back. - ANSWER-A, B
Rationale: The correct answers (A and B) are the appropriate administration of
ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A
cotton ball should be placed in the outermost canal (D). The auricle is pulled
down and back for a child younger than 3 years of age, but not an adult (E).
The nurse is evaluating measures implemented for the non-responsive client.
Which findings indicate the effectiveness of the care delivered? (Select all that
apply.)
A. Footboard at the end of the bed
B. Heals without redness bilaterally
C. Skin intact on the back
D. Sheepskin booties in place
E. Elbow joint fully flexes and extends.
F. Ankle joint rotates 360 degrees freely. - ANSWER-B, C, E, F
Rationale: The footboard helps prevent foot drop, but does not measure the
effectiveness of the treatment. The sheepskin booties are in place to protect the
, heal, but they do not demonstrate the effectiveness. The remaining are
assessments that demonstrate the interventions are effective.
The nurse is assessing several clients prior to surgery. Which factor in a client's
history poses the greatest threat for complications to occur during surgery?
A. Taking birth control pills for the past 2 years
B. Taking anticoagulants for the past year
C. Recently completing antibiotic therapy
D. Having taken laxatives PRN for the last 6 months - ANSWER-B
Rationale: Anticoagulants increase the risk for bleeding during surgery, which
can pose a threat for the development of surgical complications. The health care
provider should be informed that the client is taking these drugs. Although
clients who take birth control pills may be more susceptible to the development
of thrombi, such problems usually occur postoperatively. A client with option C
or D is at less of a surgical risk than with option B.
The nurse is evaluating the chart of a client scheduled for surgery in 1 hour.
When viewing the consent form, the nurse notes the surgeon's signature, but not
the client's signature. What steps must the nurse take? (Select all that apply.)
A. Call the surgeon.
B. Ask the client, "Did your surgeon explain the procedure to you?"
C. Have the client's spouse sign the form.
D. Ask the client, "Do you have any questions?"
E. Witness the signature.
F. Obtain the consent. - ANSWER-B, D, E
Rationale:It is the surgeon's responsibility to review the procedure with the
client until the client has no further questions. The nurse can verify the review
by the surgeon and ask if the client has any further questions. If the client has
questions, the nurse must call in the surgeon. When the nurse signs the consent
form, the nurse is witnessing the signature only.
