HESI RN FUNDAMENTALS EXIT EXAM LATEST
2026-2026 ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
1
The nurse is called to the waiting room of a pediatric clinic. B, C, D
The frantic mother states, "I think my 4-month-old baby is Rationale: The fingers are placed at the same location on an infant as chest compressions
choking!" What steps will the nurse take? (Select all that for CPR; however, the nurse must deliver five chest thrusts, after the five back slaps. Blind
apply.) sweeps are not used as this action may push the object deeper into the throat. The
A. remaining steps are correct.
Compress the chest once between the nipples with two
fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with blood.
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
1/43
,When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the nurse a
A. wide base of support while stabilizing the client's knees when assisting to a standing
Place the chair parallel to the bed, with its back toward the position. The chair should be placed at a 45-degree angle to the bed, with the back of
head of the bed and assist the client in moving to the chair. the chair toward the head of the bed. Clients should never be lifted under the axillae; this
B. could damage nerves and strain the nurse's back. The client should be instructed to use
With the nurse's feet spread apart and knees aligned with the the arms of the chair and should never place his or her arms around the nurse's neck; this
client's knees, stand and pivot the client into the chair. places undue stress on the nurse's neck and back and increases the risk for a fall.
C.
Assist the client to a standing position by gently lifting upward,
underneath the axillae.
D.
Stand beside the client, place the client's arms around the
nurse's neck, and gently move the client to the chair.
How many mL will the nurse document on the client's intake Answer: 2155
and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood pressure in B
the lower extremity. Which observation of this procedure Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse
requires the nurse to intervene with the UAP's approach? is the site for auscultation when the blood pressure cuff is applied around the thigh. The
A. nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A
The cuff wraps around the girth of the leg. ensures an accurate assessment, and option C provides the best access to the artery.
B. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in
the The UAP auscultates the popliteal pulse with the cuff on the brachial artery.
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.
2/43
,During a clinic visit, the mother of a 7-year-old reports to the D
nurse that her child is often awake until midnight playing and is Rationale: School-age children often resist bedtime. The nurse should begin by assessing
then very difficult to awaken in the morning for school. Which the environment of the home to determine factors that may not be conducive to the
assessment data should the nurse obtain in response to the establishment of bedtime rituals that promote sleep. Option A often causes daytime
mother's concern? fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful
A. data. The nurse cannot determine option C.
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
The nurse identifies a potential for infection in a client with B
partial-thickness (second-degree) and full-thickness (third- Rationale: Careful handwashing technique is the single most effective intervention for the
degree) burns. What action has the highest priority in prevention of contamination to all clients. Option A reverses the hypovolemia that initially
decreasing the client's risk of infection? accompanies burn trauma but is not related to decreasing the proliferation of infective
A. organisms. Options C and D are recommended by various burn centers as possible ways
Administration of plasma expanders to reduce the chance of infection. Option B is a proven technique to prevent infection.
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by gravity has Rationale: The nurse should first check the tubing and height of the bag on the IV pole,
slowed, even though the venous access site is healthy. What which are common factors that may slow the rate. Gravity infusion rates are influenced by
should the nurse do next? the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity,
A. client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow
Apply a warm compress proximal to the site. the rate and often responds to warmth over the vessel, but the nurse should first adjust
B. the IV pole height. The nurse may need to adjust the stabilizing tape on a positional
Check for kinks in the tubing and raise the IV pole. needle or flush the venous access with normal saline, but less invasive actions should
be
C. implemented first.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
3/43
, The nurse manager of a skilled nursing (chronic care) unit is A
instructing UAPs on ways to prevent complications of Rationale: Performing range-of-motion exercises is beneficial in reducing contractures
immobility. Which action should be included in this instruction? around joints. Options B, C, and D are all potentially harmful practices that place the
A. immobile client at risk of complications.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift.
The nurse administered 10 mg of diazepam to the preoperative B, C, D
client. What steps will the nurse take next? (Select all that Rationale: Diazepam is a common preoperative medication. Close observation by placing
apply.) the client close to the nurse's station is not necessary. The medication has a sedative
A. effect and the client should not get out of bed, even with assistance. The remaining
Place the client in the bed next to the nurse's station. selections are correct.
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
A terminally ill client tells the nurse, "I am so tired and in so B
much pain! Please help me to die." Which is the best response Rationale: The nurse should first assess the client's feelings about death and determine
for the nurse to provide? the extent to which this statement expresses the client's true feelings. The client may need
A. additional pain management, but further assessment is needed before implementing
Administer the prescribed maximum dose of pain medication. option A. Options C and D are both premature interventions and should not be
B. implemented until further assessment is obtained.
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.
4/43
2026-2026 ACTUAL EXAM 100 QUESTIONS AND
CORRECT ANSWERS WITH RATIOANLES
(VERIFIED ANSWERS)
1
The nurse is called to the waiting room of a pediatric clinic. B, C, D
The frantic mother states, "I think my 4-month-old baby is Rationale: The fingers are placed at the same location on an infant as chest compressions
choking!" What steps will the nurse take? (Select all that for CPR; however, the nurse must deliver five chest thrusts, after the five back slaps. Blind
apply.) sweeps are not used as this action may push the object deeper into the throat. The
A. remaining steps are correct.
Compress the chest once between the nipples with two
fingers.
B.
Note any obstruction or absence of breathing.
C.
Deliver five backslaps between the shoulder blades.
D.
Place the infant over the nurse's arm.
E.
Perform a blind finger sweep.
Which fluid will the nurse select to administer with the B
prescribed blood transfusion? Rationale: Normal saline solution is the only solution that is compatible with blood.
A.
5% Dextrose and water
B.
Normal saline
C.
Lactated Ringers solution
D.
5% Dextrose and lactated ringers
1/43
,When assisting a client from the bed to a chair, which B
procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and affords the nurse a
A. wide base of support while stabilizing the client's knees when assisting to a standing
Place the chair parallel to the bed, with its back toward the position. The chair should be placed at a 45-degree angle to the bed, with the back of
head of the bed and assist the client in moving to the chair. the chair toward the head of the bed. Clients should never be lifted under the axillae; this
B. could damage nerves and strain the nurse's back. The client should be instructed to use
With the nurse's feet spread apart and knees aligned with the the arms of the chair and should never place his or her arms around the nurse's neck; this
client's knees, stand and pivot the client into the chair. places undue stress on the nurse's neck and back and increases the risk for a fall.
C.
Assist the client to a standing position by gently lifting upward,
underneath the axillae.
D.
Stand beside the client, place the client's arms around the
nurse's neck, and gently move the client to the chair.
How many mL will the nurse document on the client's intake Answer: 2155
and output record from the items listed? _____ mL Rationale: 1200 + 240 (8 oz) + 240 (1 cup) + 120 (4 oz) + 355 = 2155
1200 mL water
4 ounce container of gelatin
8 ounces of orange juice
355 mL can of soda1 cup of soup
The nurse observes a UAP taking a client's blood pressure in B
the lower extremity. Which observation of this procedure Rationale: When obtaining the blood pressure in the lower extremities, the popliteal pulse
requires the nurse to intervene with the UAP's approach? is the site for auscultation when the blood pressure cuff is applied around the thigh. The
A. nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A
The cuff wraps around the girth of the leg. ensures an accurate assessment, and option C provides the best access to the artery.
B. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in
the The UAP auscultates the popliteal pulse with the cuff on the brachial artery.
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.
2/43
,During a clinic visit, the mother of a 7-year-old reports to the D
nurse that her child is often awake until midnight playing and is Rationale: School-age children often resist bedtime. The nurse should begin by assessing
then very difficult to awaken in the morning for school. Which the environment of the home to determine factors that may not be conducive to the
assessment data should the nurse obtain in response to the establishment of bedtime rituals that promote sleep. Option A often causes daytime
mother's concern? fatigue rather than resistance to going to sleep. Option B is unlikely to provide useful
A. data. The nurse cannot determine option C.
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
The nurse identifies a potential for infection in a client with B
partial-thickness (second-degree) and full-thickness (third- Rationale: Careful handwashing technique is the single most effective intervention for the
degree) burns. What action has the highest priority in prevention of contamination to all clients. Option A reverses the hypovolemia that initially
decreasing the client's risk of infection? accompanies burn trauma but is not related to decreasing the proliferation of infective
A. organisms. Options C and D are recommended by various burn centers as possible ways
Administration of plasma expanders to reduce the chance of infection. Option B is a proven technique to prevent infection.
B.
Use of careful handwashing technique
C.
Application of a topical antibacterial cream
D.
Limiting visitors to the client with burns
The nurse assesses a 2-year-old who is admitted for B
dehydration and finds that the peripheral IV rate by gravity has Rationale: The nurse should first check the tubing and height of the bag on the IV pole,
slowed, even though the venous access site is healthy. What which are common factors that may slow the rate. Gravity infusion rates are influenced by
should the nurse do next? the height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity,
A. client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow
Apply a warm compress proximal to the site. the rate and often responds to warmth over the vessel, but the nurse should first adjust
B. the IV pole height. The nurse may need to adjust the stabilizing tape on a positional
Check for kinks in the tubing and raise the IV pole. needle or flush the venous access with normal saline, but less invasive actions should
be
C. implemented first.
Adjust the tape that stabilizes the needle.
D.
Flush with normal saline and recount the drop rate.
3/43
, The nurse manager of a skilled nursing (chronic care) unit is A
instructing UAPs on ways to prevent complications of Rationale: Performing range-of-motion exercises is beneficial in reducing contractures
immobility. Which action should be included in this instruction? around joints. Options B, C, and D are all potentially harmful practices that place the
A. immobile client at risk of complications.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift.
The nurse administered 10 mg of diazepam to the preoperative B, C, D
client. What steps will the nurse take next? (Select all that Rationale: Diazepam is a common preoperative medication. Close observation by placing
apply.) the client close to the nurse's station is not necessary. The medication has a sedative
A. effect and the client should not get out of bed, even with assistance. The remaining
Place the client in the bed next to the nurse's station. selections are correct.
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
A terminally ill client tells the nurse, "I am so tired and in so B
much pain! Please help me to die." Which is the best response Rationale: The nurse should first assess the client's feelings about death and determine
for the nurse to provide? the extent to which this statement expresses the client's true feelings. The client may need
A. additional pain management, but further assessment is needed before implementing
Administer the prescribed maximum dose of pain medication. option A. Options C and D are both premature interventions and should not be
B. implemented until further assessment is obtained.
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.
4/43
