HESI 799 RN Exit Exam 1,EXIT HESI EXAM,Exit HESI 3 160 ,B
HESI Study Questions (taken from HESI NCLEX-RN book),HESI
NCLEX Review Exam ,HESI Obstetrics/Maternity Practice,Peds
HESI Version 2 Questions And Answers,Pharmacology HESI
Practice ,Module three He
SECTION I: FUNDAMENTALS & SAFETY (Q1–15)
1. A nurse is preparing to administer a nasogastric tube feeding. Which action should the nurse
take first?
A. Verify tube placement by aspirating gastric contents
B. Elevate the head of the bed to 30–45 degrees
C. Check the residual volume
D. Flush the tube with 30 mL of water
Correct Answer: B
Rationale: Elevating the head of the bed to at least 30–45 degrees is the priority to prevent
aspiration before initiating a tube feeding. Placement verification, residual check, and flushing
follow, but airway protection comes first.
2. A client with a new colostomy is being taught about ostomy care. Which statement by the
client indicates understanding?
A. "I should change the pouch every day."
B. "I can cut the skin barrier opening 1/8 inch larger than the stoma."
C. "I will avoid all foods that cause gas."
D. "I should irrigate the colostomy daily regardless of type."
Correct Answer: B
Rationale: The barrier opening should be no more than 1/8 inch larger than the stoma to
protect peristomal skin. Pouches are typically changed every 3–7 days, not daily. Gas-producing
foods are limited as tolerated, not eliminated. Irrigation is only for descending/sigmoid
colostomies.
3. A nurse is caring for a client on fall precautions. Which intervention is the highest priority?
A. Place the call light within reach
B. Apply a bed alarm
,C. Keep the bed in the lowest position with wheels locked
D. Instruct the client to call for assistance before getting up
Correct Answer: C
Rationale: Keeping the bed low and locked is the most fundamental environmental safety
measure that prevents injury if the client attempts to get up. All options are appropriate, but
the lowest bed position directly reduces fall injury risk.
4. (SATA) A nurse is assessing a client for pressure injury risk. Which factors increase risk? (Select
all that apply.)
A. Serum albumin 2.1 g/dL
B. Braden score of 22
C. Incontinence
D. Immobility
E. Moisture-associated skin damage
Correct Answers: A, C, D, E
Rationale: Low albumin indicates malnutrition and impaired healing. Incontinence and
moisture damage macerate skin. Immobility reduces perfusion and increases pressure. A
Braden score of 22 indicates low risk (lower scores = higher risk).
5. A nurse is performing a sterile dressing change. Which action breaks sterile technique?
A. Opening the sterile package away from the body
B. Holding sterile items above waist level
C. Reaching across the sterile field with a bare hand
D. Placing sterile supplies on the sterile drape
Correct Answer: C
Rationale: Reaching across a sterile field contaminates it. Sterile items must be kept above
waist level and within the field; opening packages away from the body and placing supplies on
the drape are correct.
6. A client is on contact precautions. Which PPE is required upon entering the room?
A. Gloves and gown
B. Mask and goggles
,C. N95 respirator
D. Gloves only
Correct Answer: A
Rationale: Contact precautions require gloves and gown. Masks/goggles are for
droplet/airborne or splash risk. N95 is for airborne precautions (e.g., TB, measles).
7. A nurse is teaching a client about crutch walking. Which gait is appropriate for a client who
can bear full weight on both legs?
A. Two-point gait
B. Three-point gait
C. Swing-through gait
D. Four-point gait
Correct Answer: A
Rationale: The two-point gait allows full weight bearing on both legs and is faster than the
four-point. Three-point is for non-weight-bearing on one leg; swing-through requires strong
upper body and is used for non-weight-bearing.
8. A nurse is caring for a client with dysphagia. Which intervention should the nurse implement?
A. Provide thin liquids
B. Have the client lie flat while eating
C. Place food on the unaffected side of the mouth
D. Encourage talking during meals
Correct Answer: C
Rationale: Placing food on the unaffected side facilitates swallowing. Thin liquids increase
aspiration risk; the client should be upright; talking during meals increases aspiration risk.
9. A client reports pain 8/10. The nurse administers morphine IV. Which assessment is most
important 15 minutes later?
A. Pain level
B. Respiratory rate
C. Blood pressure
D. Bowel sounds
, Correct Answer: B
Rationale: IV morphine peaks rapidly; respiratory depression is the most life-threatening
adverse effect. Respiratory rate is the priority assessment.
10. A nurse is documenting a wound. Which description correctly uses the nursing process?
A. "Wound looks bad"
B. "2 cm × 3 cm reddened area on sacrum, no drainage"
C. "Client probably has an infection"
D. "Wound healing well"
Correct Answer: B
Rationale: Objective, measurable documentation is required. Subjective terms like "looks
bad," "probably," or "healing well" are not acceptable.
11. A nurse is preparing to insert an indwelling urinary catheter. Which action is correct?
A. Use clean technique
B. Inflate the balloon before verifying urine return
C. Clean the meatus with sterile solution front to back
D. Advance the catheter until resistance is met, then stop
Correct Answer: C
Rationale: Sterile technique is required. Cleansing front to back prevents contamination.
The balloon is inflated only after urine return confirms bladder placement; the catheter is
advanced to the bifurcation (Y), not stopped at resistance.
12. (SATA) Which findings indicate a client is experiencing fluid volume deficit? (Select all that
apply.)
A. Tachycardia
B. Hypotension
C. Bounding pulses
D. Decreased skin turgor
E. Weight gain
Correct Answers: A, B, D
Rationale: Fluid deficit causes tachycardia, hypotension, and poor skin turgor. Bounding
pulses and weight gain indicate fluid excess.
HESI Study Questions (taken from HESI NCLEX-RN book),HESI
NCLEX Review Exam ,HESI Obstetrics/Maternity Practice,Peds
HESI Version 2 Questions And Answers,Pharmacology HESI
Practice ,Module three He
SECTION I: FUNDAMENTALS & SAFETY (Q1–15)
1. A nurse is preparing to administer a nasogastric tube feeding. Which action should the nurse
take first?
A. Verify tube placement by aspirating gastric contents
B. Elevate the head of the bed to 30–45 degrees
C. Check the residual volume
D. Flush the tube with 30 mL of water
Correct Answer: B
Rationale: Elevating the head of the bed to at least 30–45 degrees is the priority to prevent
aspiration before initiating a tube feeding. Placement verification, residual check, and flushing
follow, but airway protection comes first.
2. A client with a new colostomy is being taught about ostomy care. Which statement by the
client indicates understanding?
A. "I should change the pouch every day."
B. "I can cut the skin barrier opening 1/8 inch larger than the stoma."
C. "I will avoid all foods that cause gas."
D. "I should irrigate the colostomy daily regardless of type."
Correct Answer: B
Rationale: The barrier opening should be no more than 1/8 inch larger than the stoma to
protect peristomal skin. Pouches are typically changed every 3–7 days, not daily. Gas-producing
foods are limited as tolerated, not eliminated. Irrigation is only for descending/sigmoid
colostomies.
3. A nurse is caring for a client on fall precautions. Which intervention is the highest priority?
A. Place the call light within reach
B. Apply a bed alarm
,C. Keep the bed in the lowest position with wheels locked
D. Instruct the client to call for assistance before getting up
Correct Answer: C
Rationale: Keeping the bed low and locked is the most fundamental environmental safety
measure that prevents injury if the client attempts to get up. All options are appropriate, but
the lowest bed position directly reduces fall injury risk.
4. (SATA) A nurse is assessing a client for pressure injury risk. Which factors increase risk? (Select
all that apply.)
A. Serum albumin 2.1 g/dL
B. Braden score of 22
C. Incontinence
D. Immobility
E. Moisture-associated skin damage
Correct Answers: A, C, D, E
Rationale: Low albumin indicates malnutrition and impaired healing. Incontinence and
moisture damage macerate skin. Immobility reduces perfusion and increases pressure. A
Braden score of 22 indicates low risk (lower scores = higher risk).
5. A nurse is performing a sterile dressing change. Which action breaks sterile technique?
A. Opening the sterile package away from the body
B. Holding sterile items above waist level
C. Reaching across the sterile field with a bare hand
D. Placing sterile supplies on the sterile drape
Correct Answer: C
Rationale: Reaching across a sterile field contaminates it. Sterile items must be kept above
waist level and within the field; opening packages away from the body and placing supplies on
the drape are correct.
6. A client is on contact precautions. Which PPE is required upon entering the room?
A. Gloves and gown
B. Mask and goggles
,C. N95 respirator
D. Gloves only
Correct Answer: A
Rationale: Contact precautions require gloves and gown. Masks/goggles are for
droplet/airborne or splash risk. N95 is for airborne precautions (e.g., TB, measles).
7. A nurse is teaching a client about crutch walking. Which gait is appropriate for a client who
can bear full weight on both legs?
A. Two-point gait
B. Three-point gait
C. Swing-through gait
D. Four-point gait
Correct Answer: A
Rationale: The two-point gait allows full weight bearing on both legs and is faster than the
four-point. Three-point is for non-weight-bearing on one leg; swing-through requires strong
upper body and is used for non-weight-bearing.
8. A nurse is caring for a client with dysphagia. Which intervention should the nurse implement?
A. Provide thin liquids
B. Have the client lie flat while eating
C. Place food on the unaffected side of the mouth
D. Encourage talking during meals
Correct Answer: C
Rationale: Placing food on the unaffected side facilitates swallowing. Thin liquids increase
aspiration risk; the client should be upright; talking during meals increases aspiration risk.
9. A client reports pain 8/10. The nurse administers morphine IV. Which assessment is most
important 15 minutes later?
A. Pain level
B. Respiratory rate
C. Blood pressure
D. Bowel sounds
, Correct Answer: B
Rationale: IV morphine peaks rapidly; respiratory depression is the most life-threatening
adverse effect. Respiratory rate is the priority assessment.
10. A nurse is documenting a wound. Which description correctly uses the nursing process?
A. "Wound looks bad"
B. "2 cm × 3 cm reddened area on sacrum, no drainage"
C. "Client probably has an infection"
D. "Wound healing well"
Correct Answer: B
Rationale: Objective, measurable documentation is required. Subjective terms like "looks
bad," "probably," or "healing well" are not acceptable.
11. A nurse is preparing to insert an indwelling urinary catheter. Which action is correct?
A. Use clean technique
B. Inflate the balloon before verifying urine return
C. Clean the meatus with sterile solution front to back
D. Advance the catheter until resistance is met, then stop
Correct Answer: C
Rationale: Sterile technique is required. Cleansing front to back prevents contamination.
The balloon is inflated only after urine return confirms bladder placement; the catheter is
advanced to the bifurcation (Y), not stopped at resistance.
12. (SATA) Which findings indicate a client is experiencing fluid volume deficit? (Select all that
apply.)
A. Tachycardia
B. Hypotension
C. Bounding pulses
D. Decreased skin turgor
E. Weight gain
Correct Answers: A, B, D
Rationale: Fluid deficit causes tachycardia, hypotension, and poor skin turgor. Bounding
pulses and weight gain indicate fluid excess.
