HESI RN EXIT LEGACY V2 160 PREP SET 2026
TESTED QUESTIONS WITH RATIONALE
◉ The client states to the nurse, "This medication makes my mouth
so dry." What are the nurse's suggestions to quench the client's
thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
E.
Keep a few pieces of hard candy with you to suck on. Answer: B, C, E
Rationale: Sodas do not tend to be thirst quenching because of the
amount of sugar in them that draws fluid into the GI system. Citrus
infused water quenches thirst, as does consuming frozen liquids.
Hard candy can produce moisture in the mouth.
,◉ The nurse notes in the client's plan of care altered sleep patterns
related to nocturia. Which nursing actions are important for the
nurse to provide? (Select all that apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern. Answer: A, E
Rationale: Nocturia is urination during the night. Option A is helpful
to decrease the production of urine, thus decreasing the need to void
at night. Option E gives the nurse the client's baseline sleep pattern.
Option B helps prevent bladder infections. Option C may promote
sleep, but the fluid will contribute to nocturia. Option D may result
in urinary incontinence if the client is sedated and does not awaken
to void.
◉ The nurse is counting a client's respiratory rate. During a 30-
second interval, the nurse counts six respirations and the client
coughs three times. In repeating the count for a second 30-second
,interval, the nurse counts eight respirations. Which respiratory rate
will the nurse document?
A. 15
B. 16
C. 17
D. 28 Answer: B
Rationale: The most accurate respiratory rate is the second count
obtained by the nurse, which was not interrupted by coughing.
Because it was counted for 30 seconds, the rate should be doubled.
Options A, C, and D are inaccurate recordings.
◉ The nurse is preparing to administer a bolus tube feeding. What
steps must the nurse include prior to administering the feeding?
(Select all that apply.)
A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
C.
Position the client in semi-Fowler's position.
D.
Irrigate the lumen after the contents are replaced.
E.
, Warm the feeding to room temperature.
F.
Assess the pH of the stomach contents. Answer: A, B, E, F
Rationale: The client needs to be in high Fowler's position to
decrease the risk of aspiration. Irrigation of the lumen is only
necessary if there is an obstruction. The contents were replaced, so
there is no suspicion of obstruction. The remaining steps are correct.
◉ Ten minutes after signing an operative permit for a fractured hip,
an older client states, "The aliens will be coming to get me soon!"
and falls asleep. Which action should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
B.
Assess the client's neurologic status.
C.
Notify the surgeon about the comment.
D.
Ask the client's family to co-sign the operative permit. Answer: B
Rationale: This statement may indicate that the client is confused.
Informed consent must be provided by a mentally competent
individual, so the nurse should further assess the client's neurologic
status to be sure that the client understands and can legally provide
consent for surgery. Option A does not provide sufficient follow-up.
TESTED QUESTIONS WITH RATIONALE
◉ The client states to the nurse, "This medication makes my mouth
so dry." What are the nurse's suggestions to quench the client's
thirst? (Select all that apply.)
A.
Drink 2, 8 ounce glasses of lemon-lime soda every day.
B.
Infuse your water with fresh citrus fruits to quench your thirst.
C.
Freeze strawberries and water together in popsicle mold.
D.
Add ginger ale to your daily glass of juice every day.
E.
Keep a few pieces of hard candy with you to suck on. Answer: B, C, E
Rationale: Sodas do not tend to be thirst quenching because of the
amount of sugar in them that draws fluid into the GI system. Citrus
infused water quenches thirst, as does consuming frozen liquids.
Hard candy can produce moisture in the mouth.
,◉ The nurse notes in the client's plan of care altered sleep patterns
related to nocturia. Which nursing actions are important for the
nurse to provide? (Select all that apply.)
A.
Decrease intake of fluids after the evening meal.
B.
Drink a glass of cranberry juice every day.
C.
Drink a glass of warm decaffeinated beverage at bedtime.
D.
Consult the health care provider about a sleeping pill.
E.
Assess the client's usual sleep pattern. Answer: A, E
Rationale: Nocturia is urination during the night. Option A is helpful
to decrease the production of urine, thus decreasing the need to void
at night. Option E gives the nurse the client's baseline sleep pattern.
Option B helps prevent bladder infections. Option C may promote
sleep, but the fluid will contribute to nocturia. Option D may result
in urinary incontinence if the client is sedated and does not awaken
to void.
◉ The nurse is counting a client's respiratory rate. During a 30-
second interval, the nurse counts six respirations and the client
coughs three times. In repeating the count for a second 30-second
,interval, the nurse counts eight respirations. Which respiratory rate
will the nurse document?
A. 15
B. 16
C. 17
D. 28 Answer: B
Rationale: The most accurate respiratory rate is the second count
obtained by the nurse, which was not interrupted by coughing.
Because it was counted for 30 seconds, the rate should be doubled.
Options A, C, and D are inaccurate recordings.
◉ The nurse is preparing to administer a bolus tube feeding. What
steps must the nurse include prior to administering the feeding?
(Select all that apply.)
A.
Aspirate the stomach contents.
B.
Assess bowel sounds.
C.
Position the client in semi-Fowler's position.
D.
Irrigate the lumen after the contents are replaced.
E.
, Warm the feeding to room temperature.
F.
Assess the pH of the stomach contents. Answer: A, B, E, F
Rationale: The client needs to be in high Fowler's position to
decrease the risk of aspiration. Irrigation of the lumen is only
necessary if there is an obstruction. The contents were replaced, so
there is no suspicion of obstruction. The remaining steps are correct.
◉ Ten minutes after signing an operative permit for a fractured hip,
an older client states, "The aliens will be coming to get me soon!"
and falls asleep. Which action should the nurse take next?
A.
Make the client comfortable and allow the client to sleep.
B.
Assess the client's neurologic status.
C.
Notify the surgeon about the comment.
D.
Ask the client's family to co-sign the operative permit. Answer: B
Rationale: This statement may indicate that the client is confused.
Informed consent must be provided by a mentally competent
individual, so the nurse should further assess the client's neurologic
status to be sure that the client understands and can legally provide
consent for surgery. Option A does not provide sufficient follow-up.
