HESI RN FUNDAMENTALS EXIT EXAM LATEST
2026-2027 ACTUAL EXAM 300 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to
water seal. The client is using the incentive spirometer hourly while awake. Which assessment
finding warrants intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness.
c) Water seal level 2 cm below the water seal fill line.
A client with a demand pacemaker has a telemetry tracing with a pacing spike but no
corresponding QRS complex. The client's myocardium is eliciting a QRS after a delay of several
seconds. Which telemetry interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer.
a) Loss of capture.
The nurse is caring for a client who underwent surgical repair of the aorta after sustaining
injuries in a fall. Which finding indicates improved blood flow after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50.
a) Movement of lower extremities.
1
,The nurse reports findings to the healthcare provider for a client who was admitted to the
intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse
completes the report using the Situation, Background, Assessment, Recommendation (SBAR)
format, which statement best supports the nurse's reason for calling the healthcare provider?
a) Prescription for an additional respiratory treatment.
b) Admission today with difficulty breathing.
c) History of COPD.
d) Presence of expiratory wheezes in the lower lobes.
a) Prescription for an additional respiratory treatment.
The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation
due to acute respiratory failure. The family asks when the client will be extubated. Which
information should the nurse provide?
a) When the client breathes spontaneously in between mechanical ventilations.
b) Once all serum electrolyte and blood chemistry levels normalize.
c) At the completion of intravenous antibiotic therapy and the infection is resolved.
d) When the chest x-ray shows that the inflammation is resolved.
a) When the client breathes spontaneously in between mechanical ventilations.
The nurse is caring for a client with severe sepsis related to a ruptured appendix. The client is
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are
uneven and labored. Arterial blood gas (ABG) results are: pH 7.60, PaCO2 25 mmHg, HCO3 24
mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the
nurse?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds.
2
,b) Intercostal muscle retraction.
Intercostal muscle retraction
is a critical sign of respiratory muscle fatigue that is likely to lead to acute respiratory failure,
requiring intubation with mechanical ventilation
A client who is hypotensive is receiving an IV infusion of dopamine 10 mcg/kg/minute through a
peripheral line. The client reports burning at the IV site. Which action should the nurse
implement?
a) Stop the infusion and notify the healthcare provider of the findings.
b) Check the line for blood return and irrigate the peripheral IV catheter.
c) Apply a cold compress to the site and continue the infusion.
d) Slow the infusion and add a secondary IV of 0.9% sodium chloride.
a) Stop the infusion and notify the healthcare provider of the findings.
dopamine
a vasopressor, has significant vasoconstrictive action that can cause soft tissues necrosis if
extravasation occurs
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The
ABG results are: pH 7.17, PaCO2 70 mmHg, HCO3 30 mEq/liter. How should the nurse interpret
this ABG?
a) Respiratory acidosis.
b) Respiratory alkalosis.
c) Metabolic acidosis.
d) Metabolic alkalosis.
a) Respiratory acidosis.
normal Ph
7.35-7.45
normal PaCO2
35 to 45
3
, normal HCO3
22-26
The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries
sustained in a motor vehicle collision. The client has a 6 on the Glasgow Coma Scale (GCS).
Which intervention should the nurse prepare for the client?
a) Intubation with mechanical ventilation.
b) Nasogastric tube placement.
c) Advanced cardiac life support.
d) Twelve-lead electrocardiogram.
a) Intubation with mechanical ventilation.
Glasgow Coma Scale
-used to determine the level of consciousness of a client with traumatic brain injury
-a score of 6 or lower may indicate the need for mechanical ventilation
A client who has experienced trauma is admitted to the intensive care unit. The nurse's initial
assessment includes a Glasgow Coma Scale (GCS) score of 3, pupils fixed and dilated with an
absence of corneal reflex, blood pressure of 80/30 mmHg, and core temperature of 95.7° F
(35.4° C). The client's spouse asks the nurse when the client will wake up. How should the nurse
respond?
a) "Your spouse's condition indicates irreversible damage."
b) "Let me contact the healthcare provider to answer your questions."
c) "Each person is different and we need to wait and see what happens."
d) "I need to initiate the volume expanders and warming blanket to stimulate a response."
b) "Let me contact the healthcare provider to answer your questions."
The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no
spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which
intervention should the nurse implement first?
a) Assess for signs of cardiac tamponade.
b) Begin chest compressions at 120 per minute.
c) Check for responsiveness with sternal rub.
4
2026-2027 ACTUAL EXAM 300 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
Two days following cardiac bypass surgery, the nurse places a client's mediastinal chest tube to
water seal. The client is using the incentive spirometer hourly while awake. Which assessment
finding warrants intervention by the nurse?
a) Serosanguineous fluid in collection container.
b) Fluid fluctuation in tubing with respirations.
c) Water seal level 2 cm below the water seal fill line.
d) Report of chest tube insertion site tenderness.
c) Water seal level 2 cm below the water seal fill line.
A client with a demand pacemaker has a telemetry tracing with a pacing spike but no
corresponding QRS complex. The client's myocardium is eliciting a QRS after a delay of several
seconds. Which telemetry interpretation should the nurse conclude?
a) Loss of capture.
b) Ventricular fibrillation.
c) Capture from an ectopic focus.
d) A normal finding with a demand pacer.
a) Loss of capture.
The nurse is caring for a client who underwent surgical repair of the aorta after sustaining
injuries in a fall. Which finding indicates improved blood flow after the surgery?
a) Movement of lower extremities.
b) Decreased urinary output.
c) Maintained weight.
d) Blood pressure 90/50.
a) Movement of lower extremities.
1
,The nurse reports findings to the healthcare provider for a client who was admitted to the
intensive care unit today with chronic obstructive pulmonary disease (COPD). When the nurse
completes the report using the Situation, Background, Assessment, Recommendation (SBAR)
format, which statement best supports the nurse's reason for calling the healthcare provider?
a) Prescription for an additional respiratory treatment.
b) Admission today with difficulty breathing.
c) History of COPD.
d) Presence of expiratory wheezes in the lower lobes.
a) Prescription for an additional respiratory treatment.
The nurse is caring for a client in the intensive care unit who is receiving mechanical ventilation
due to acute respiratory failure. The family asks when the client will be extubated. Which
information should the nurse provide?
a) When the client breathes spontaneously in between mechanical ventilations.
b) Once all serum electrolyte and blood chemistry levels normalize.
c) At the completion of intravenous antibiotic therapy and the infection is resolved.
d) When the chest x-ray shows that the inflammation is resolved.
a) When the client breathes spontaneously in between mechanical ventilations.
The nurse is caring for a client with severe sepsis related to a ruptured appendix. The client is
diaphoretic and reports lower extremity spasms. The nurse observes respirations that are
uneven and labored. Arterial blood gas (ABG) results are: pH 7.60, PaCO2 25 mmHg, HCO3 24
mEq/L, and PaO2 24 mmHg. Which assessment finding warrants immediate intervention by the
nurse?
a) Increased pulmonary secretions.
b) Intercostal muscle retraction.
c) Decreased breath sounds.
d) Bronchovesicular breath sounds.
2
,b) Intercostal muscle retraction.
Intercostal muscle retraction
is a critical sign of respiratory muscle fatigue that is likely to lead to acute respiratory failure,
requiring intubation with mechanical ventilation
A client who is hypotensive is receiving an IV infusion of dopamine 10 mcg/kg/minute through a
peripheral line. The client reports burning at the IV site. Which action should the nurse
implement?
a) Stop the infusion and notify the healthcare provider of the findings.
b) Check the line for blood return and irrigate the peripheral IV catheter.
c) Apply a cold compress to the site and continue the infusion.
d) Slow the infusion and add a secondary IV of 0.9% sodium chloride.
a) Stop the infusion and notify the healthcare provider of the findings.
dopamine
a vasopressor, has significant vasoconstrictive action that can cause soft tissues necrosis if
extravasation occurs
The nurse is analyzing an arterial blood gas (ABG) of a client who is mechanically ventilated. The
ABG results are: pH 7.17, PaCO2 70 mmHg, HCO3 30 mEq/liter. How should the nurse interpret
this ABG?
a) Respiratory acidosis.
b) Respiratory alkalosis.
c) Metabolic acidosis.
d) Metabolic alkalosis.
a) Respiratory acidosis.
normal Ph
7.35-7.45
normal PaCO2
35 to 45
3
, normal HCO3
22-26
The nurse is caring for a client admitted to the critical care unit with multiple traumatic injuries
sustained in a motor vehicle collision. The client has a 6 on the Glasgow Coma Scale (GCS).
Which intervention should the nurse prepare for the client?
a) Intubation with mechanical ventilation.
b) Nasogastric tube placement.
c) Advanced cardiac life support.
d) Twelve-lead electrocardiogram.
a) Intubation with mechanical ventilation.
Glasgow Coma Scale
-used to determine the level of consciousness of a client with traumatic brain injury
-a score of 6 or lower may indicate the need for mechanical ventilation
A client who has experienced trauma is admitted to the intensive care unit. The nurse's initial
assessment includes a Glasgow Coma Scale (GCS) score of 3, pupils fixed and dilated with an
absence of corneal reflex, blood pressure of 80/30 mmHg, and core temperature of 95.7° F
(35.4° C). The client's spouse asks the nurse when the client will wake up. How should the nurse
respond?
a) "Your spouse's condition indicates irreversible damage."
b) "Let me contact the healthcare provider to answer your questions."
c) "Each person is different and we need to wait and see what happens."
d) "I need to initiate the volume expanders and warming blanket to stimulate a response."
b) "Let me contact the healthcare provider to answer your questions."
The cardiac monitor alarms and the nurse finds a client with no palpable carotid pulse and no
spontaneous respirations. The cardiac monitor displays a normal sinus rhythm. Which
intervention should the nurse implement first?
a) Assess for signs of cardiac tamponade.
b) Begin chest compressions at 120 per minute.
c) Check for responsiveness with sternal rub.
4
