HESI RN EXIT EXAM 2025–2026 A+ TEST BANK: REAL EXAM
QUESTIONS, ACCURATE ANSWERS & FULL RATIONALES;
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.
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.
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,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.
Clamp the nasogastric tube.
B.
Confirm placement of the tube.
C.
Use a syringe to instill the medications.
D.
Turn off the intermittent suction device. - ANSWER--D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the
stomach before instilling the medications. To prevent immediate removal of the instilled medications
and allow absorption, the tube should be clamped for a period of time before reconnecting the
suction.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about
drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
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,B.
"Apple juice is the most useful in acidifying the urine."
C.
"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics." - ANSWER--C
Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia
coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective
as cranberry juice in preventing UTIs.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after getting
home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked questions about
medications.
B.
Advise the client to obtain a current edition of a drug reference book from a local bookstore or
library.
C.
Reassure the client that information about the medication is included in the written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any questions arise. - ANSWER--
D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or
health care provider if any questions arise. Options A, B, and C may all include useful information,
but these sources of information cannot evaluate the nature of the client's questions and the follow-
up needed.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise
will the nurse select to prepare the medication?
A.
30 mL medication cup
B.
10 mL medication spoon
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, C.
3 mL needleless syringe
D.
5 mL medicine dropper - ANSWER--C
Rationale: Accuracy is most important when delivering small amounts of medication to a child. The
most accurate dispensing devise is the 3 mL needleless syringe that is marked off in increments of
tenths.
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will
cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers. - ANSWER--D
Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to
neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these
clients. The remaining options pose a low risk for infection.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert.
Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
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QUESTIONS, ACCURATE ANSWERS & FULL RATIONALES;
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.
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.
1|Page
,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.
Clamp the nasogastric tube.
B.
Confirm placement of the tube.
C.
Use a syringe to instill the medications.
D.
Turn off the intermittent suction device. - ANSWER--D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube in the
stomach before instilling the medications. To prevent immediate removal of the instilled medications
and allow absorption, the tube should be clamped for a period of time before reconnecting the
suction.
A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about
drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?
A.
"Orange juice has vitamin C that deters bacterial growth."
2|Page
,B.
"Apple juice is the most useful in acidifying the urine."
C.
"Cranberry juice stops pathogens' adherence to the bladder."
D.
"Grapefruit juice increases absorption of most antibiotics." - ANSWER--C
Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia
coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective
as cranberry juice in preventing UTIs.
After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after getting
home. How should the nurse respond?
A.
Provide the client with a list of Internet sites that answer frequently asked questions about
medications.
B.
Advise the client to obtain a current edition of a drug reference book from a local bookstore or
library.
C.
Reassure the client that information about the medication is included in the written instructions.
D.
Encourage the client to call the clinic nurse or health care provider if any questions arise. - ANSWER--
D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the nurse or
health care provider if any questions arise. Options A, B, and C may all include useful information,
but these sources of information cannot evaluate the nature of the client's questions and the follow-
up needed.
The nurse is preparing a liquid medication for a 2-year-old. The dose is 2.2 mL. What delivery devise
will the nurse select to prepare the medication?
A.
30 mL medication cup
B.
10 mL medication spoon
3|Page
, C.
3 mL needleless syringe
D.
5 mL medicine dropper - ANSWER--C
Rationale: Accuracy is most important when delivering small amounts of medication to a child. The
most accurate dispensing devise is the 3 mL needleless syringe that is marked off in increments of
tenths.
The nurse is providing care to a client receiving high doses of chemotherapy. Which situation will
cause the nurse to intervene for this client?
A.
Co-workers walk into the room with a 2′ × 3′ get well card.
B.
A neighbor stops by with a box of chocolate candy.
C.
A clergy member places a book of prayers at the client's bedside.
D.
The florist delivers an arrangement of fresh flowers. - ANSWER--D
Rationale: A common side effect of chemotherapy is the inability to fight infection secondary to
neutropenia. Fresh fruits and fresh flowers are sources of infection that must be avoided for these
clients. The remaining options pose a low risk for infection.
The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert.
Which nursing actions are correct? (Select all that apply.)
A.
Place the client in a high Fowler position.
B.
Explain that placement of the tube is painless.
C.
Measure the tube from the tip of the nose to the umbilicus.
D.
Instruct the client to swallow after the tube has passed the pharynx.
E.
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