HESI RN FUNDAMENTALS EXIT EXAM WITH DETAILED
CORRECT ANSWERS AND RATIONALES | GRADED A+
1. 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.
2. 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. 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.
3. A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and
applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg
amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the
nurse?
A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C. There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act.
, D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be
proved.
Correct Answer: C
Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide
reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights
protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to
revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done
in good faith or that reasonable care was not provided.
4. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now
requesting to go to the bathroom. What is the priority nursing action for this client?
A. Assist the client to walk to the bathroom and do not leave the client alone.
B. Request that the UAP assist the client onto a bedpan.
C. Ask if the client needs to have a bowel movement or void.
D. Assess the client's bladder to determine if the client needs to urinate.
Correct Answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these
medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not
necessary as long as safety is ensured.
5. The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the
highest priority?
A. Assist the client with daily cleansing.
B. Tell the client that incontinence happens with aging.
C. Offer 200 mL of fluid every 2 hours while awake.
D. Take the client's temperature every 4 hours.
Correct Answer: D
Rationale: Indwelling urinary catheters are a major source of infection. Taking the client's temperature allows
for early detection of systemic infection.
6. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A. Remind the child to clean his genital area.
B. Defer perineal care because of the child's age.
C. Retract the foreskin gently to cleanse the penis.
D. Ask the parents why the child is not circumcised.
Correct Answer: C
CORRECT ANSWERS AND RATIONALES | GRADED A+
1. 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.
2. 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. 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.
3. A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and
applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg
amputated and sues the nurse for malpractice. Which statement reflects the likely outcome for the
nurse?
A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case.
B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C. There will be no judgment against the nurse, whose actions are protected under the Good Samaritan Act.
, D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be
proved.
Correct Answer: C
Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide
reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights
protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to
revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done
in good faith or that reasonable care was not provided.
4. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now
requesting to go to the bathroom. What is the priority nursing action for this client?
A. Assist the client to walk to the bathroom and do not leave the client alone.
B. Request that the UAP assist the client onto a bedpan.
C. Ask if the client needs to have a bowel movement or void.
D. Assess the client's bladder to determine if the client needs to urinate.
Correct Answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, and individuals taking these
medications are at greater risk for falls. The nurse should assist the client to the bathroom. A bedpan is not
necessary as long as safety is ensured.
5. The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the
highest priority?
A. Assist the client with daily cleansing.
B. Tell the client that incontinence happens with aging.
C. Offer 200 mL of fluid every 2 hours while awake.
D. Take the client's temperature every 4 hours.
Correct Answer: D
Rationale: Indwelling urinary catheters are a major source of infection. Taking the client's temperature allows
for early detection of systemic infection.
6. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
A. Remind the child to clean his genital area.
B. Defer perineal care because of the child's age.
C. Retract the foreskin gently to cleanse the penis.
D. Ask the parents why the child is not circumcised.
Correct Answer: C
