HESI RN EXIT EXAM TEST BANK 2025–2026: COMPLETE
VERIFIED QUESTIONS WITH DETAILED RATIONALES (A+
GUARANTEED);
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 - ANSWER--A, C, E
Rationale: Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV
site would need to be changed before starting the solution. Potassium solutions must infuse with an
infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not
lemon yellow. The remaining selections are not concerning to the nurse.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many
milliliters should the nurse administer? _____ mL (Round to the nearest tenth.)
** 10mg/2mL - ANSWER--0.8
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
In taking a client's history, the nurse asks about the stool characteristics. Which description should
the nurse report to the health care provider as soon as possible?
A.
Daily black, sticky stool
B.
Daily dark brown stool
C.
Firm brown stool every other day
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,D.
Soft light brown stool twice a day - ANSWER--A
Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to
the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options
B and D are variations of normal.
The nurse is preparing to administer a new medication through an existing IV line containing a
vasopressor. What action must the nurse take first?
A.
Flush the line with normal saline at the same rate as the vasopressor.
B.
Administer the medication at the prescribed IV rate.
C.
Start a second IV line to administer the new medication.
D.
Call the health care provider to change the order for the new medication to po. - ANSWER--A
Rationale: The medication in the IV line between the post and the patient contains the vasopressor
medication. The nurse must continue to administer the vasopressor medication at the prescribed
rate by injecting normal saline at that rate. Once the line is clear of the vasopressor medication, then
the nurse can inject the new medication at the prescribed rate. There is no need to start a second IV
or change the route of administration.
The nurse is working at a community-based clinic. Which client's spiritual well-being concerns the
nurse the most?
A.
Roman Catholic woman considering an abortion
B.
Jewish man considering hospice care for his wife
C.
Seventh-Day Adventist who needs a blood transfusion
D.
Muslim man who needs a total knee replacement - ANSWER--A
Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision
may place the client at risk for spiritual distress. There is no prohibition of hospice care for members
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,of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions.
There is no conflict in the Muslim faith with regard to joint replacement.
The mental health nurse plans to discuss a client's depression with the health care provider in the
emergency department. There are two clients sitting across from the emergency department desk.
Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. - ANSWER--D
Rationale: The best nursing action is to discuss the client another time. Confidentiality must be
observed at all times, so the nurse should not discuss the client when the conversation can be
overheard by others. Details of the client can be identified when referring to the client by gender or
age, even when not using the client's name.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports, "I am still unable to sleep, despite following the same
routine every night." Which action should the nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. - ANSWER--D
Rationale: The nurse should first evaluate whether the client has been adhering to the original
instructions. A verbal report of the client's routine will provide more specific information than the
client's written diary. The nurse can then determine which changes need to be made. The routine
practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.
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, A client is laughing at a television program when the evening nurse enters the room. The client
states, "My foot is hurting. I would like a pain pill." How should the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control. - ANSWER--A
Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain
helps the nurse determine which pain medication should be administered and also provides a
baseline for evaluating the effectiveness of the medication. Medicating for pain should not be
delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be
used as an adjunct to pain medication, not instead of medication.
Which action is most important for the nurse to include in the plan of care for a client at high risk for
the development of postoperative thrombus formation?
A.
Instruct in the use of the incentive spirometer.
B.
Elevate the head of the bed during all meals.
C.
Use aseptic technique to change the dressing.
D.
Encourage frequent ambulation in the hallway. - ANSWER--D
Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the
nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the
hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B
reduces the risk for aspiration. Option C reduces the risk for postoperative infection.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A.
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VERIFIED QUESTIONS WITH DETAILED RATIONALES (A+
GUARANTEED);
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 - ANSWER--A, C, E
Rationale: Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV
site would need to be changed before starting the solution. Potassium solutions must infuse with an
infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not
lemon yellow. The remaining selections are not concerning to the nurse.
The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many
milliliters should the nurse administer? _____ mL (Round to the nearest tenth.)
** 10mg/2mL - ANSWER--0.8
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
In taking a client's history, the nurse asks about the stool characteristics. Which description should
the nurse report to the health care provider as soon as possible?
A.
Daily black, sticky stool
B.
Daily dark brown stool
C.
Firm brown stool every other day
1|Page
,D.
Soft light brown stool twice a day - ANSWER--A
Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to
the health care provider promptly. Option C indicates constipation, which is a lesser priority. Options
B and D are variations of normal.
The nurse is preparing to administer a new medication through an existing IV line containing a
vasopressor. What action must the nurse take first?
A.
Flush the line with normal saline at the same rate as the vasopressor.
B.
Administer the medication at the prescribed IV rate.
C.
Start a second IV line to administer the new medication.
D.
Call the health care provider to change the order for the new medication to po. - ANSWER--A
Rationale: The medication in the IV line between the post and the patient contains the vasopressor
medication. The nurse must continue to administer the vasopressor medication at the prescribed
rate by injecting normal saline at that rate. Once the line is clear of the vasopressor medication, then
the nurse can inject the new medication at the prescribed rate. There is no need to start a second IV
or change the route of administration.
The nurse is working at a community-based clinic. Which client's spiritual well-being concerns the
nurse the most?
A.
Roman Catholic woman considering an abortion
B.
Jewish man considering hospice care for his wife
C.
Seventh-Day Adventist who needs a blood transfusion
D.
Muslim man who needs a total knee replacement - ANSWER--A
Rationale: In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision
may place the client at risk for spiritual distress. There is no prohibition of hospice care for members
2|Page
,of the Jewish faith. Jehovah's Witnesses, not Seventh-Day Adventists, prohibit blood transfusions.
There is no conflict in the Muslim faith with regard to joint replacement.
The mental health nurse plans to discuss a client's depression with the health care provider in the
emergency department. There are two clients sitting across from the emergency department desk.
Which nursing action is best?
A.
Only refer to the client by gender.
B.
Identify the client only by age.
C.
Avoid using the client's name.
D.
Discuss the client another time. - ANSWER--D
Rationale: The best nursing action is to discuss the client another time. Confidentiality must be
observed at all times, so the nurse should not discuss the client when the conversation can be
overheard by others. Details of the client can be identified when referring to the client by gender or
age, even when not using the client's name.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports, "I am still unable to sleep, despite following the same
routine every night." Which action should the nurse take next?
A.
Instruct the client to add regular exercise as a daily routine.
B.
Determine if the client has been keeping a sleep diary.
C.
Encourage the client to continue the routine until sleep is achieved.
D.
Ask the client to describe the routine he is currently following. - ANSWER--D
Rationale: The nurse should first evaluate whether the client has been adhering to the original
instructions. A verbal report of the client's routine will provide more specific information than the
client's written diary. The nurse can then determine which changes need to be made. The routine
practiced by the client is clearly unsuccessful, so encouragement alone is insufficient.
3|Page
, A client is laughing at a television program when the evening nurse enters the room. The client
states, "My foot is hurting. I would like a pain pill." How should the nurse respond?
A.
Ask the client to rate the pain using a 1 to 10 scale.
B.
Encourage the client to wait until bedtime for the pill.
C.
Attend to an acutely ill client's needs first because this client is laughing.
D.
Instruct the client in the use of deep breathing exercises for pain control. - ANSWER--A
Rationale: Obtaining a subjective estimate of the pain experience by asking the client to rate his pain
helps the nurse determine which pain medication should be administered and also provides a
baseline for evaluating the effectiveness of the medication. Medicating for pain should not be
delayed so that it can be used as a sleep medication. Option C is judgmental. Option D should be
used as an adjunct to pain medication, not instead of medication.
Which action is most important for the nurse to include in the plan of care for a client at high risk for
the development of postoperative thrombus formation?
A.
Instruct in the use of the incentive spirometer.
B.
Elevate the head of the bed during all meals.
C.
Use aseptic technique to change the dressing.
D.
Encourage frequent ambulation in the hallway. - ANSWER--D
Rationale: Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the
nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the
hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B
reduces the risk for aspiration. Option C reduces the risk for postoperative infection.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A.
4|Page
