HESI MED SURG EXIT EXAM V1 ACTUAL PAPER
2026 QUESTIONS WITH SOLUTIONS GRADED
A+
◉ How many mL will the nurse document on the client's intake and
output record from the items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup Answer: Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155
◉ The nurse observes a UAP taking a client's blood pressure in the
lower extremity. Which observation of this procedure requires the
nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower
leg.
C.
,The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in
the client's arm. Answer: B
Rationale: When obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for auscultation when the
blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg.
Option A ensures an accurate assessment, and option C provides the
best access to the artery. Systolic pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than in the brachial artery.
◉ 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 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 full-thickness (third-degree)
burns. What action has the highest priority in decreasing the client's
risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns 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. 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
2026 QUESTIONS WITH SOLUTIONS GRADED
A+
◉ How many mL will the nurse document on the client's intake and
output record from the items listed? _____ mL
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup Answer: Answer: 2155
Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 =
2155
◉ The nurse observes a UAP taking a client's blood pressure in the
lower extremity. Which observation of this procedure requires the
nurse to intervene with the UAP's approach?
A.
The cuff wraps around the girth of the leg.
B.
The UAP auscultates the popliteal pulse with the cuff on the lower
leg.
C.
,The client is placed in a prone position.
D.
The systolic reading is 20 mm Hg higher than the blood pressure in
the client's arm. Answer: B
Rationale: When obtaining the blood pressure in the lower
extremities, the popliteal pulse is the site for auscultation when the
blood pressure cuff is applied around the thigh. The nurse should
intervene with the UAP who has applied the cuff on the lower leg.
Option A ensures an accurate assessment, and option C provides the
best access to the artery. Systolic pressure in the popliteal artery is
usually 10 to 40 mm Hg higher than in the brachial artery.
◉ 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 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 full-thickness (third-degree)
burns. What action has the highest priority in decreasing the client's
risk of infection?
A.
Administration of plasma expanders
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns 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. 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
