HESI RN FUNDAMENTALS
EXIT EXAM 2025-2026
COMPREHENSIVE STUDY GUIDE
SECTION 1: SAFETY & FALL PREVENTION
QUESTION 1
When assisting a client from bed to chair, which procedure is best?
ANSWER
B. With nurse's feet spread apart and knees aligned with client's knees, stand
and pivot the client into the chair
RATIONALE / EXPLANATION
Wide base of support stabilizes client's knees during transfer. Chair at 45° angle to bed. Never lift
under axillae (nerve damage) or have client's arms around nurse's neck.
QUESTION 2
A client given barbiturate for sleep requests to go to the bathroom. Priority nursing action?
ANSWER
A. Assist the client to walk to the bathroom and do not leave the client alone
RATIONALE / EXPLANATION
Barbiturates cause CNS depression - increased fall risk. Nurse must accompany client. A bedpan
is not necessary if safety is ensured.
QUESTION 3
A client 5 feet from bathroom states 'I feel faint' and starts to fall. Priority action?
ANSWER
D. Gently lower the client to the floor
RATIONALE / EXPLANATION
Priority is preventing injury to client and nurse. Lower to floor when client cannot support own
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,weight. Check pulse after client is safe.
QUESTION 4
When turning an immobile bedridden client without assistance, which action ensures safety?
ANSWER
B. Put bed rails up on the side opposite from the nurse
RATIONALE / EXPLANATION
Bed rails prevent client from falling out of bed on the opposite side while nurse is turning from
one side.
QUESTION 5
A 65-year-old wheelchair-mobile client has sacral redness. Most important instruction?
ANSWER
B. 'Change positions in the chair frequently'
RATIONALE / EXPLANATION
Pressure is the most significant factor in pressure ulcer development. Frequent position changes
relieve pressure.
QUESTION 6
What instruction is most important for preventing venous thrombosis in limited mobility?
ANSWER
C. Dorsiflex and plantarflex the feet 10 times each hour
RATIONALE / EXPLANATION
Foot exercises promote venous return and prevent venous stasis that leads to thrombus
formation.
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, SECTION 2: IV THERAPY & FLUID ADMINISTRATION
QUESTION 7
Which fluid is compatible with blood transfusion?
ANSWER
B. Normal saline
RATIONALE / EXPLANATION
Normal saline is the ONLY solution compatible with blood. Dextrose and LR can cause
hemolysis.
QUESTION 8
A 2-year-old's peripheral IV has slowed but site is healthy. What should nurse do next?
ANSWER
B. Check for kinks in tubing and raise the IV pole
RATIONALE / EXPLANATION
Check common factors first: tubing kinks, IV pole height. Less invasive actions before adjusting
needle or flushing.
QUESTION 9
Which documentation identifies IV placement site correctly?
ANSWER
B. Right cephalic vein
RATIONALE / EXPLANATION
Document the anatomic name of the vein accessed. Cephalic vein is large, superficial, and
commonly used for IV access.
QUESTION 10
Preparing IV for 80-year-old receiving antibiotics every 8 hours with good PO intake. What
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, supplies?
ANSWER
B. Normal saline in 10 mL syringe
C. Clear plastic sterile bandage
D. Skin preparation antiseptic swab
RATIONALE / EXPLANATION
16 gauge is too large for elderly (use 20-22G). Small flush syringe (not 1000 mL bag) for
intermittent therapy.
QUESTION 11
Potassium in 100 mL NS - which findings concern the nurse?
ANSWER
A. Red and swollen peripheral IV site
C. Starting infusion without an infusion device
E. Solution is lemon-yellow color
RATIONALE / EXPLANATION
K+ causes phlebitis (red/swollen = infection). Must use pump to prevent accidental bolus.
Solution should be clear, not yellow.
QUESTION 12
New IV bag hung at 1845 at 75 mL/hr. At 1915, less than 50 mL left. Nurse's next action?
ANSWER
D. Auscultate the client's lungs
RATIONALE / EXPLANATION
~950 mL infused rapidly = risk for fluid overload. Assess for crackles/pulmonary edema first, then
notify charge nurse/HCP.
QUESTION 13
IV infiltration signs - which findings support evaluation?
ANSWER
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EXIT EXAM 2025-2026
COMPREHENSIVE STUDY GUIDE
SECTION 1: SAFETY & FALL PREVENTION
QUESTION 1
When assisting a client from bed to chair, which procedure is best?
ANSWER
B. With nurse's feet spread apart and knees aligned with client's knees, stand
and pivot the client into the chair
RATIONALE / EXPLANATION
Wide base of support stabilizes client's knees during transfer. Chair at 45° angle to bed. Never lift
under axillae (nerve damage) or have client's arms around nurse's neck.
QUESTION 2
A client given barbiturate for sleep requests to go to the bathroom. Priority nursing action?
ANSWER
A. Assist the client to walk to the bathroom and do not leave the client alone
RATIONALE / EXPLANATION
Barbiturates cause CNS depression - increased fall risk. Nurse must accompany client. A bedpan
is not necessary if safety is ensured.
QUESTION 3
A client 5 feet from bathroom states 'I feel faint' and starts to fall. Priority action?
ANSWER
D. Gently lower the client to the floor
RATIONALE / EXPLANATION
Priority is preventing injury to client and nurse. Lower to floor when client cannot support own
Page 1 of 32
,weight. Check pulse after client is safe.
QUESTION 4
When turning an immobile bedridden client without assistance, which action ensures safety?
ANSWER
B. Put bed rails up on the side opposite from the nurse
RATIONALE / EXPLANATION
Bed rails prevent client from falling out of bed on the opposite side while nurse is turning from
one side.
QUESTION 5
A 65-year-old wheelchair-mobile client has sacral redness. Most important instruction?
ANSWER
B. 'Change positions in the chair frequently'
RATIONALE / EXPLANATION
Pressure is the most significant factor in pressure ulcer development. Frequent position changes
relieve pressure.
QUESTION 6
What instruction is most important for preventing venous thrombosis in limited mobility?
ANSWER
C. Dorsiflex and plantarflex the feet 10 times each hour
RATIONALE / EXPLANATION
Foot exercises promote venous return and prevent venous stasis that leads to thrombus
formation.
Page 2 of 32
, SECTION 2: IV THERAPY & FLUID ADMINISTRATION
QUESTION 7
Which fluid is compatible with blood transfusion?
ANSWER
B. Normal saline
RATIONALE / EXPLANATION
Normal saline is the ONLY solution compatible with blood. Dextrose and LR can cause
hemolysis.
QUESTION 8
A 2-year-old's peripheral IV has slowed but site is healthy. What should nurse do next?
ANSWER
B. Check for kinks in tubing and raise the IV pole
RATIONALE / EXPLANATION
Check common factors first: tubing kinks, IV pole height. Less invasive actions before adjusting
needle or flushing.
QUESTION 9
Which documentation identifies IV placement site correctly?
ANSWER
B. Right cephalic vein
RATIONALE / EXPLANATION
Document the anatomic name of the vein accessed. Cephalic vein is large, superficial, and
commonly used for IV access.
QUESTION 10
Preparing IV for 80-year-old receiving antibiotics every 8 hours with good PO intake. What
Page 3 of 32
, supplies?
ANSWER
B. Normal saline in 10 mL syringe
C. Clear plastic sterile bandage
D. Skin preparation antiseptic swab
RATIONALE / EXPLANATION
16 gauge is too large for elderly (use 20-22G). Small flush syringe (not 1000 mL bag) for
intermittent therapy.
QUESTION 11
Potassium in 100 mL NS - which findings concern the nurse?
ANSWER
A. Red and swollen peripheral IV site
C. Starting infusion without an infusion device
E. Solution is lemon-yellow color
RATIONALE / EXPLANATION
K+ causes phlebitis (red/swollen = infection). Must use pump to prevent accidental bolus.
Solution should be clear, not yellow.
QUESTION 12
New IV bag hung at 1845 at 75 mL/hr. At 1915, less than 50 mL left. Nurse's next action?
ANSWER
D. Auscultate the client's lungs
RATIONALE / EXPLANATION
~950 mL infused rapidly = risk for fluid overload. Assess for crackles/pulmonary edema first, then
notify charge nurse/HCP.
QUESTION 13
IV infiltration signs - which findings support evaluation?
ANSWER
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