CONCORDE CAREER COLLEGES NURSING
270HESI EXIT EXAM — 260 PRACTICE
QUESTIONS WITH ANSWERS & RATIONALES
FUNDAMENTALS OF NURSING
1. A nurse is preparing to administer a medication to a client. Which action should the
nurse perform FIRST?
A) Check the medication administration record B) Verify the client's identity using two
identifiers C) Wash hands before handling the medication D) Assess the client for allergies
D) Assess the client for allergies (correct answer)
RATIONALE: Before administering any medication, the nurse must first assess for
allergies to prevent a potentially life-threatening allergic reaction. This is a priority safety
step that precedes all other actions including identity verification and hand hygiene.
2. A nurse is caring for a client who is on contact precautions. Which personal protective
equipment (PPE) is REQUIRED when entering the room?
A) Mask and goggles only B) Gown and gloves C) N95 respirator and gloves D) Face shield
only
B) Gown and gloves (correct answer)
RATIONALE: Contact precautions require the use of a gown and gloves when entering the
client's room to prevent transmission of microorganisms through direct or indirect contact.
An N95 respirator is required for airborne precautions, not contact precautions.
3. A client has a nursing diagnosis of impaired skin integrity related to immobility. Which
intervention is MOST appropriate?
,A) Reposition the client every 4 hours B) Apply a moisture barrier cream once daily C)
Reposition the client every 2 hours D) Encourage fluid intake of 1,000 mL per day
C) Reposition the client every 2 hours (correct answer)
RATIONALE: Repositioning every 2 hours is the standard of care for preventing and
managing pressure injuries in immobile clients. This relieves pressure on bony
prominences and promotes circulation to the skin, reducing the risk of further skin
breakdown.
4. A nurse is performing a head-to-toe assessment. Which finding requires IMMEDIATE
follow-up?
A) Bilateral crackles in the lung bases B) Bowel sounds present in all four quadrants C) Heart
rate of 72 beats per minute D) Blood pressure of 118/76 mmHg
A) Bilateral crackles in the lung bases (correct answer)
RATIONALE: Bilateral crackles in the lung bases may indicate fluid accumulation, such
as pulmonary edema or pneumonia, which requires immediate follow-up. The other
findings are within normal range and do not require urgent intervention.
5. The nurse is teaching a client about the use of a walker. Which statement by the client
indicates a need for FURTHER teaching?
A) "I will advance the walker before stepping forward." B) "I will keep all four legs of the
walker on the floor at all times." C) "I will put my strong leg forward first when walking." D) "I
will advance the walker and both feet at the same time."
D) "I will advance the walker and both feet at the same time." (correct answer)
RATIONALE: The correct technique is to advance the walker first, then step into it — not
to move both simultaneously. Moving both at once creates instability and increases the risk
of falls. The client should move the walker, then step the weaker leg forward, then the
stronger leg.
6. A nurse delegates the task of measuring vital signs to an unlicensed assistive personnel
(UAP). Which vital sign finding should the UAP report to the nurse IMMEDIATELY?
,A) Temperature of 37.2°C (99°F) B) Blood pressure of 88/50 mmHg C) Pulse of 78 beats per
minute D) Respiratory rate of 16 breaths per minute
B) Blood pressure of 88/50 mmHg (correct answer)
RATIONALE: A blood pressure of 88/50 mmHg is critically low and indicates hypotension,
which could signal shock or another life-threatening condition. The UAP must report this
finding immediately so the nurse can assess the client and initiate appropriate
interventions.
7. A nurse is inserting a urinary catheter in a female client. After cleansing the urethral
meatus and inserting the catheter, urine does not return. What is the MOST likely
explanation?
A) The catheter is in the bladder but kinked B) The catheter has been inserted into the vagina C)
The client is dehydrated D) The catheter balloon has been inflated prematurely
B) The catheter has been inserted into the vagina (correct answer)
RATIONALE: In female clients, the vaginal opening is near the urethral meatus. If the
catheter is accidentally inserted into the vagina, no urine will return. The nurse should
leave that catheter in place as a landmark, obtain a new sterile catheter, and insert it into
the correct urethral opening.
8. A client is ordered to receive a blood transfusion. Fifteen minutes into the transfusion,
the client reports chills, back pain, and fever. What is the nurse's PRIORITY action?
A) Slow the transfusion rate B) Administer diphenhydramine as ordered C) Stop the transfusion
immediately D) Notify the healthcare provider first
C) Stop the transfusion immediately (correct answer)
RATIONALE: The symptoms described — chills, back pain, and fever shortly after
beginning a transfusion — are classic signs of a hemolytic transfusion reaction, which can
be life-threatening. The nurse must stop the transfusion immediately, keep the IV line open
with normal saline, and then notify the provider and the blood bank.
9. A nurse is caring for a client with a nasogastric (NG) tube. Which action BEST confirms
tube placement before feeding?
, A) Auscultating the stomach while injecting air B) Checking the pH of aspirated contents C)
Measuring the external length of the tube D) Asking the client if they feel the tube in place
B) Checking the pH of aspirated contents (correct answer)
RATIONALE: The most reliable bedside method for confirming NG tube placement is
checking the pH of aspirated gastric contents. A pH of 0–5 confirms gastric placement.
Auscultation of air insufflation is no longer considered reliable, and external measurement
alone is insufficient to confirm correct placement.
10. A client is receiving oxygen via nasal cannula at 4 L/min. The nurse knows this delivers
approximately what percentage of oxygen?
A) 21% B) 28% C) 36% D) 44%
C) 36% (correct answer)
RATIONALE: A nasal cannula delivers approximately 24% FiO₂ at 1 L/min, with each
additional liter adding approximately 4%. At 4 L/min, the delivered FiO₂ is approximately
24% + 12% = 36%. This is an important calculation for nurses to know when managing
oxygen therapy.
MEDICAL-SURGICAL NURSING
11. A client with Type 1 diabetes mellitus is found unresponsive. The nurse's FIRST action
should be:
A) Administer glucagon intramuscularly B) Check the blood glucose level C) Call the rapid
response team D) Administer 50% dextrose intravenously
B) Check the blood glucose level (correct answer)
RATIONALE: The nurse must first assess the situation by checking the blood glucose level
to determine whether the unresponsiveness is due to hypoglycemia or hyperglycemia.
Treatment differs significantly for each condition, so assessment must precede intervention.
If glucose is critically low and IV access is available, dextrose can then be administered.
270HESI EXIT EXAM — 260 PRACTICE
QUESTIONS WITH ANSWERS & RATIONALES
FUNDAMENTALS OF NURSING
1. A nurse is preparing to administer a medication to a client. Which action should the
nurse perform FIRST?
A) Check the medication administration record B) Verify the client's identity using two
identifiers C) Wash hands before handling the medication D) Assess the client for allergies
D) Assess the client for allergies (correct answer)
RATIONALE: Before administering any medication, the nurse must first assess for
allergies to prevent a potentially life-threatening allergic reaction. This is a priority safety
step that precedes all other actions including identity verification and hand hygiene.
2. A nurse is caring for a client who is on contact precautions. Which personal protective
equipment (PPE) is REQUIRED when entering the room?
A) Mask and goggles only B) Gown and gloves C) N95 respirator and gloves D) Face shield
only
B) Gown and gloves (correct answer)
RATIONALE: Contact precautions require the use of a gown and gloves when entering the
client's room to prevent transmission of microorganisms through direct or indirect contact.
An N95 respirator is required for airborne precautions, not contact precautions.
3. A client has a nursing diagnosis of impaired skin integrity related to immobility. Which
intervention is MOST appropriate?
,A) Reposition the client every 4 hours B) Apply a moisture barrier cream once daily C)
Reposition the client every 2 hours D) Encourage fluid intake of 1,000 mL per day
C) Reposition the client every 2 hours (correct answer)
RATIONALE: Repositioning every 2 hours is the standard of care for preventing and
managing pressure injuries in immobile clients. This relieves pressure on bony
prominences and promotes circulation to the skin, reducing the risk of further skin
breakdown.
4. A nurse is performing a head-to-toe assessment. Which finding requires IMMEDIATE
follow-up?
A) Bilateral crackles in the lung bases B) Bowel sounds present in all four quadrants C) Heart
rate of 72 beats per minute D) Blood pressure of 118/76 mmHg
A) Bilateral crackles in the lung bases (correct answer)
RATIONALE: Bilateral crackles in the lung bases may indicate fluid accumulation, such
as pulmonary edema or pneumonia, which requires immediate follow-up. The other
findings are within normal range and do not require urgent intervention.
5. The nurse is teaching a client about the use of a walker. Which statement by the client
indicates a need for FURTHER teaching?
A) "I will advance the walker before stepping forward." B) "I will keep all four legs of the
walker on the floor at all times." C) "I will put my strong leg forward first when walking." D) "I
will advance the walker and both feet at the same time."
D) "I will advance the walker and both feet at the same time." (correct answer)
RATIONALE: The correct technique is to advance the walker first, then step into it — not
to move both simultaneously. Moving both at once creates instability and increases the risk
of falls. The client should move the walker, then step the weaker leg forward, then the
stronger leg.
6. A nurse delegates the task of measuring vital signs to an unlicensed assistive personnel
(UAP). Which vital sign finding should the UAP report to the nurse IMMEDIATELY?
,A) Temperature of 37.2°C (99°F) B) Blood pressure of 88/50 mmHg C) Pulse of 78 beats per
minute D) Respiratory rate of 16 breaths per minute
B) Blood pressure of 88/50 mmHg (correct answer)
RATIONALE: A blood pressure of 88/50 mmHg is critically low and indicates hypotension,
which could signal shock or another life-threatening condition. The UAP must report this
finding immediately so the nurse can assess the client and initiate appropriate
interventions.
7. A nurse is inserting a urinary catheter in a female client. After cleansing the urethral
meatus and inserting the catheter, urine does not return. What is the MOST likely
explanation?
A) The catheter is in the bladder but kinked B) The catheter has been inserted into the vagina C)
The client is dehydrated D) The catheter balloon has been inflated prematurely
B) The catheter has been inserted into the vagina (correct answer)
RATIONALE: In female clients, the vaginal opening is near the urethral meatus. If the
catheter is accidentally inserted into the vagina, no urine will return. The nurse should
leave that catheter in place as a landmark, obtain a new sterile catheter, and insert it into
the correct urethral opening.
8. A client is ordered to receive a blood transfusion. Fifteen minutes into the transfusion,
the client reports chills, back pain, and fever. What is the nurse's PRIORITY action?
A) Slow the transfusion rate B) Administer diphenhydramine as ordered C) Stop the transfusion
immediately D) Notify the healthcare provider first
C) Stop the transfusion immediately (correct answer)
RATIONALE: The symptoms described — chills, back pain, and fever shortly after
beginning a transfusion — are classic signs of a hemolytic transfusion reaction, which can
be life-threatening. The nurse must stop the transfusion immediately, keep the IV line open
with normal saline, and then notify the provider and the blood bank.
9. A nurse is caring for a client with a nasogastric (NG) tube. Which action BEST confirms
tube placement before feeding?
, A) Auscultating the stomach while injecting air B) Checking the pH of aspirated contents C)
Measuring the external length of the tube D) Asking the client if they feel the tube in place
B) Checking the pH of aspirated contents (correct answer)
RATIONALE: The most reliable bedside method for confirming NG tube placement is
checking the pH of aspirated gastric contents. A pH of 0–5 confirms gastric placement.
Auscultation of air insufflation is no longer considered reliable, and external measurement
alone is insufficient to confirm correct placement.
10. A client is receiving oxygen via nasal cannula at 4 L/min. The nurse knows this delivers
approximately what percentage of oxygen?
A) 21% B) 28% C) 36% D) 44%
C) 36% (correct answer)
RATIONALE: A nasal cannula delivers approximately 24% FiO₂ at 1 L/min, with each
additional liter adding approximately 4%. At 4 L/min, the delivered FiO₂ is approximately
24% + 12% = 36%. This is an important calculation for nurses to know when managing
oxygen therapy.
MEDICAL-SURGICAL NURSING
11. A client with Type 1 diabetes mellitus is found unresponsive. The nurse's FIRST action
should be:
A) Administer glucagon intramuscularly B) Check the blood glucose level C) Call the rapid
response team D) Administer 50% dextrose intravenously
B) Check the blood glucose level (correct answer)
RATIONALE: The nurse must first assess the situation by checking the blood glucose level
to determine whether the unresponsiveness is due to hypoglycemia or hyperglycemia.
Treatment differs significantly for each condition, so assessment must precede intervention.
If glucose is critically low and IV access is available, dextrose can then be administered.
