HESI FUNDAMENTALS EXIT EXAM
QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A client with dehydration has a serum sodium level of 152 mEq/L.
Which intervention should the nurse implement first?
A. Encourage oral intake of water
B. Administer a hypertonic IV solution
C. Assess for neurological changes
D. Restrict sodium intake
Answer: C
Rationale: Hypernatremia can cause neurological changes such as
confusion, seizures, and lethargy. Assessment should be prioritized to
identify complications early.
,2. A nurse is teaching a client about metformin. Which statement indicates
the client understands the teaching?
A. “I will stop taking it if my blood sugar is normal.”
B. “I should avoid alcohol while taking this medication.”
C. “I can take it with a glass of orange juice.”
D. “I will increase my vitamin C intake.”
Answer: B
Rationale: Alcohol increases the risk of lactic acidosis with metformin.
Clients should avoid alcohol.
3. A postoperative client is at risk for deep vein thrombosis (DVT). Which
intervention is most important?
A. Encourage bed rest
B. Apply sequential compression devices
C. Provide high-calorie meals
D. Teach coughing and deep breathing
Answer: B
Rationale: SCDs help prevent venous stasis, reducing the risk of DVT.
4. A client with COPD reports increased shortness of breath. Which
position should the nurse assist the client into?
A. Supine
B. Trendelenburg
C. High Fowler’s
D. Prone
Answer: C
Rationale: High Fowler’s improves lung expansion and oxygenation.
5. A nurse is caring for a client with a nasogastric tube. The nurse notes
the drainage is green and has a foul odor. What should the nurse do
first?
A. Reposition the tube
B. Document the finding
C. Notify the provider
D. Irrigate the tube
Answer: C
, Rationale: Foul odor and green drainage may indicate infection or
obstruction; provider notification is necessary.
6. A client is prescribed lisinopril. Which adverse effect should the nurse
teach the client to report immediately?
A. Dry cough
B. Headache
C. Facial swelling
D. Constipation
Answer: C
Rationale: Angioedema (facial swelling) is a life-threatening reaction
requiring immediate attention.
7. A client has a potassium level of 2.9 mEq/L. Which finding should the
nurse expect?
A. Hyperactive bowel sounds
B. Muscle weakness
C. Bradycardia
D. Hypertension
Answer: B
Rationale: Hypokalemia causes muscle weakness, cramps, and fatigue.
8. A nurse is administering a blood transfusion. The client develops chills
and fever. What should the nurse do first?
A. Stop the transfusion
B. Increase the infusion rate
C. Administer acetaminophen
D. Notify the provider after the transfusion
Answer: A
Rationale: Chills and fever are signs of a transfusion reaction. The
transfusion must be stopped immediately.
9. A client with congestive heart failure is prescribed furosemide. Which
assessment finding is most important to monitor?
A. Lung sounds
B. Bowel sounds
C. Skin turgor
, D. Vision changes
Answer: A
Rationale: Furosemide can cause fluid loss; monitoring lung sounds helps
detect pulmonary edema improvement or worsening.
10. A client is scheduled for a colonoscopy. Which pre-procedure
instruction is most important?
A. Avoid dairy products
B. Maintain a clear liquid diet
C. Take aspirin the morning of the procedure
D. Increase fiber intake
Answer: B
Rationale: Clear liquid diet reduces stool and improves visualization during
colonoscopy.
11. A client with diabetes mellitus has a blood glucose level of 52 mg/dL.
The client is awake and oriented. Which action should the nurse take
first?
A. Administer IV glucose
B. Provide 4 oz of orange juice
C. Give a dose of insulin
D. Encourage exercise
Answer: B
Rationale: For a conscious hypoglycemic client, fast-acting oral glucose is
first.
12. A client with a stage II pressure ulcer is receiving wound care. Which
finding indicates healing?
A. Increased drainage
B. Presence of slough
C. Decreased wound size
D. Black eschar formation
Answer: C
Rationale: A decrease in wound size indicates healing.
QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES
GRADED A+ LATEST
1. A client with dehydration has a serum sodium level of 152 mEq/L.
Which intervention should the nurse implement first?
A. Encourage oral intake of water
B. Administer a hypertonic IV solution
C. Assess for neurological changes
D. Restrict sodium intake
Answer: C
Rationale: Hypernatremia can cause neurological changes such as
confusion, seizures, and lethargy. Assessment should be prioritized to
identify complications early.
,2. A nurse is teaching a client about metformin. Which statement indicates
the client understands the teaching?
A. “I will stop taking it if my blood sugar is normal.”
B. “I should avoid alcohol while taking this medication.”
C. “I can take it with a glass of orange juice.”
D. “I will increase my vitamin C intake.”
Answer: B
Rationale: Alcohol increases the risk of lactic acidosis with metformin.
Clients should avoid alcohol.
3. A postoperative client is at risk for deep vein thrombosis (DVT). Which
intervention is most important?
A. Encourage bed rest
B. Apply sequential compression devices
C. Provide high-calorie meals
D. Teach coughing and deep breathing
Answer: B
Rationale: SCDs help prevent venous stasis, reducing the risk of DVT.
4. A client with COPD reports increased shortness of breath. Which
position should the nurse assist the client into?
A. Supine
B. Trendelenburg
C. High Fowler’s
D. Prone
Answer: C
Rationale: High Fowler’s improves lung expansion and oxygenation.
5. A nurse is caring for a client with a nasogastric tube. The nurse notes
the drainage is green and has a foul odor. What should the nurse do
first?
A. Reposition the tube
B. Document the finding
C. Notify the provider
D. Irrigate the tube
Answer: C
, Rationale: Foul odor and green drainage may indicate infection or
obstruction; provider notification is necessary.
6. A client is prescribed lisinopril. Which adverse effect should the nurse
teach the client to report immediately?
A. Dry cough
B. Headache
C. Facial swelling
D. Constipation
Answer: C
Rationale: Angioedema (facial swelling) is a life-threatening reaction
requiring immediate attention.
7. A client has a potassium level of 2.9 mEq/L. Which finding should the
nurse expect?
A. Hyperactive bowel sounds
B. Muscle weakness
C. Bradycardia
D. Hypertension
Answer: B
Rationale: Hypokalemia causes muscle weakness, cramps, and fatigue.
8. A nurse is administering a blood transfusion. The client develops chills
and fever. What should the nurse do first?
A. Stop the transfusion
B. Increase the infusion rate
C. Administer acetaminophen
D. Notify the provider after the transfusion
Answer: A
Rationale: Chills and fever are signs of a transfusion reaction. The
transfusion must be stopped immediately.
9. A client with congestive heart failure is prescribed furosemide. Which
assessment finding is most important to monitor?
A. Lung sounds
B. Bowel sounds
C. Skin turgor
, D. Vision changes
Answer: A
Rationale: Furosemide can cause fluid loss; monitoring lung sounds helps
detect pulmonary edema improvement or worsening.
10. A client is scheduled for a colonoscopy. Which pre-procedure
instruction is most important?
A. Avoid dairy products
B. Maintain a clear liquid diet
C. Take aspirin the morning of the procedure
D. Increase fiber intake
Answer: B
Rationale: Clear liquid diet reduces stool and improves visualization during
colonoscopy.
11. A client with diabetes mellitus has a blood glucose level of 52 mg/dL.
The client is awake and oriented. Which action should the nurse take
first?
A. Administer IV glucose
B. Provide 4 oz of orange juice
C. Give a dose of insulin
D. Encourage exercise
Answer: B
Rationale: For a conscious hypoglycemic client, fast-acting oral glucose is
first.
12. A client with a stage II pressure ulcer is receiving wound care. Which
finding indicates healing?
A. Increased drainage
B. Presence of slough
C. Decreased wound size
D. Black eschar formation
Answer: C
Rationale: A decrease in wound size indicates healing.
