HESI RN FUNDAMENTALS EXIT EXAM LATEST
2026-2027 ACTUAL EXAM 100 QUESTIONS
AND CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
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. - Correct AnswerD
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.
Page 1 of 98
,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 - Correct AnswerC
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.
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.)
Page 2 of 98
,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. - Correct AnswerB, 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.
In assisting an older adult client prepare to take a tub bath, which
nursing action is most important?
A.
Check the bath water temperature.
B.
Page 3 of 98
, Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. - Correct AnswerA
Rationale: To prevent burns or excessive chilling, the nurse must check
the bath water temperature. Options B, C, and D promote comfort and
privacy and are important interventions but are of less priority than
promoting safety
The nurse is preparing an IV solution containing 10 mEq of potassium in
100 mL of normal saline. Which findings would concern the nurse?
(Select all that apply.)
A.
A red and swollen peripheral IV site
B.
An order to infuse the solution at 50 mL/hr
C.
Starting the infusion without an infusion devise
D.
Inverting the potassium solution every 30 minutes while infusing
E.
The solution is a lemon-yellow color - Correct AnswerA, C, E
Page 4 of 98
2026-2027 ACTUAL EXAM 100 QUESTIONS
AND CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
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. - Correct AnswerD
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.
Page 1 of 98
,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 - Correct AnswerC
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.
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.)
Page 2 of 98
,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. - Correct AnswerB, 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.
In assisting an older adult client prepare to take a tub bath, which
nursing action is most important?
A.
Check the bath water temperature.
B.
Page 3 of 98
, Shut the bathroom door.
C.
Ensure that the client has voided.
D.
Provide extra towels. - Correct AnswerA
Rationale: To prevent burns or excessive chilling, the nurse must check
the bath water temperature. Options B, C, and D promote comfort and
privacy and are important interventions but are of less priority than
promoting safety
The nurse is preparing an IV solution containing 10 mEq of potassium in
100 mL of normal saline. Which findings would concern the nurse?
(Select all that apply.)
A.
A red and swollen peripheral IV site
B.
An order to infuse the solution at 50 mL/hr
C.
Starting the infusion without an infusion devise
D.
Inverting the potassium solution every 30 minutes while infusing
E.
The solution is a lemon-yellow color - Correct AnswerA, C, E
Page 4 of 98
