HESI RN FUNDAMENTALS EXIT EXAM
ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
2026/2027 LATEST UPDATE
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until
midnight playing and is then very difficult to awaken in the morning for school. Which assessment data
should the nurse obtain in response to the mother's concern? A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - CORRECT ANSWER-D
Rationale: School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the establishment of
bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to
going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and
fullthickness (third-degree) burns. What action has the highest priority in decreasing the client's risk
of infection? A.
Administration of plasma expanders
B.
1
,Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - CORRECT ANSWER-B
Rationale: Careful handwashing technique is the single most effective intervention for the prevention
of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn
trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a
proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by
gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. - CORRECT ANSWER-B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which are
common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag,
tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in
the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over
the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the
stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive
actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent
complications of immobility. Which action should be included in this instruction? A.
Perform range-of-motion exercises to prevent contractures.
B.
2
,Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - CORRECT ANSWER-A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints.
Options B, C, and D are all potentially harmful practices that place the immobile client at risk of
complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse take
next? (Select all that apply.) A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - CORRECT ANSWER-B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by placing the client
close to the nurse's station is not necessary. The medication has a sedative effect and the client should
not get out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which
is the best response for the nurse to provide? A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
3
, Refer the client to the ethics committee of her local health care facility. - CORRECT ANSWER-B
Rationale: The nurse should first assess the client's feelings about death and determine the extent to
which this statement expresses the client's true feelings. The client may need additional pain
management, but further assessment is needed before implementing option A. Options C and D are
both premature interventions and should not be implemented until further assessment is obtained.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my
4month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. - CORRECT ANSWER-B, C, D
Rationale: The fingers are placed at the same location on an infant as chest compressions for CPR;
however, the nurse must deliver five chest thrusts, after the five back slaps. Blind sweeps are not used
as this action may push the object deeper into the throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
4
ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
2026/2027 LATEST UPDATE
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until
midnight playing and is then very difficult to awaken in the morning for school. Which assessment data
should the nurse obtain in response to the mother's concern? A.
The occurrence of any episodes of sleep apnea
B.
The child's blood pressure, pulse, and respirations
C.
Length of rapid eye movement (REM) sleep that the child is experiencing
D.
Description of the family's home environment - CORRECT ANSWER-D
Rationale: School-age children often resist bedtime. The nurse should begin by assessing the
environment of the home to determine factors that may not be conducive to the establishment of
bedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistance to
going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine option C.
The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and
fullthickness (third-degree) burns. What action has the highest priority in decreasing the client's risk
of infection? A.
Administration of plasma expanders
B.
1
,Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns - CORRECT ANSWER-B
Rationale: Careful handwashing technique is the single most effective intervention for the prevention
of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn
trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a
proven technique to prevent infection.
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by
gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A.
Apply a warm compress proximal to the site.
B.
Check for kinks in the tubing and raise the IV pole.
C.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate. - CORRECT ANSWER-B
Rationale: The nurse should first check the tubing and height of the bag on the IV pole, which are
common factors that may slow the rate. Gravity infusion rates are influenced by the height of the bag,
tubing clamp closure or kinks, needle size or position, fluid viscosity, client blood pressure (crying in
the pediatric client), and infiltration. Venospasm can slow the rate and often responds to warmth over
the vessel, but the nurse should first adjust the IV pole height. The nurse may need to adjust the
stabilizing tape on a positional needle or flush the venous access with normal saline, but less invasive
actions should be implemented first.
The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent
complications of immobility. Which action should be included in this instruction? A.
Perform range-of-motion exercises to prevent contractures.
B.
2
,Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - CORRECT ANSWER-A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures around joints.
Options B, C, and D are all potentially harmful practices that place the immobile client at risk of
complications.
The nurse administered 10 mg of diazepam to the preoperative client. What steps will the nurse take
next? (Select all that apply.) A.
Place the client in the bed next to the nurse's station.
B.
Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - CORRECT ANSWER-B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by placing the client
close to the nurse's station is not necessary. The medication has a sedative effect and the client should
not get out of bed, even with assistance. The remaining selections are correct.
A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which
is the best response for the nurse to provide? A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
3
, Refer the client to the ethics committee of her local health care facility. - CORRECT ANSWER-B
Rationale: The nurse should first assess the client's feelings about death and determine the extent to
which this statement expresses the client's true feelings. The client may need additional pain
management, but further assessment is needed before implementing option A. Options C and D are
both premature interventions and should not be implemented until further assessment is obtained.
The nurse is called to the waiting room of a pediatric clinic. The frantic mother states, "I think my
4month-old baby is choking!" What steps will the nurse take? (Select all that apply.)
A.
Compress the chest once between the nipples with two fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep. - CORRECT ANSWER-B, C, D
Rationale: The fingers are placed at the same location on an infant as chest compressions for CPR;
however, the nurse must deliver five chest thrusts, after the five back slaps. Blind sweeps are not used
as this action may push the object deeper into the throat. The remaining steps are correct.
Which fluid will the nurse select to administer with the prescribed blood transfusion?
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
4
