HESI RN EXIT EXAM (V5) 2025 ACTUAL EXAM VERIFIED
QUESTIONS AND ANSWERS 100% CORRECT – LATEST 2025
/2026- GRADE A+ GUARANTEED PASS
A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing and
has a severe headache along with nausea. Her arterial blood gases are: ph 7.50; paco2 30
mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate intervention by the
nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath - ANSWER-d. Fruity breath
When performing postural drainage on a client with chronic obstructive pulmonary disease,
which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals - ANSWER-a. Explain that the client may be
placed in five positions
A young male client with testicular cancer has a living will that describes his desire that no
extraordinary measures be taken to save his life. The health care provider knows the client has a
good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action
should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
1|Page
,D. Ask the family to review options with the client - ANSWER-A. Initiate an Ethics Committee
review of the case
In observing a client's face, which assessment finding requires the most immediate intervention
by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted - ANSWER-b. Oral mucosa is cyanotic
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski
reflex. Which action should the nurse take in response to the finding?
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment - ANSWER-d. Complete a thorough
neurological assessment
Which action should the nurse take first after obtaining a urine specimen for culture and
sensitivity from an indwelling urinary catheter?
a. Ensure that the drainage bag is attached to the bed frame
b. Ensure continued sterility of the specimen container
c. Securely fasten the clamp on the drainage bag
d. Label the container with the clients identifiers - ANSWER-c. Securely fasten the clamp on the
drainage bag
?
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,The home health nurse observes an older client with unilateral weakness place the walker in
front of the chair for support while rising to a standing position. Which action should the nurse
take?
a. Hold the Walker securely to prevent slipping when the client rises
b. Applied gait belt to assist the client to rise out of the chair
c. Instruct the client to use the arms of the chair for support
d. Encourage the client to use the weaker leg with the walker when rising - ANSWER-a. Hold the
walker securely to prevent slipping when the client rises
A client with cancer complains of fever, chills, malaise, and headache following administration
of a colony stimulating factor. Which nursing intervention is most beneficial in helping to reduce
the flu like symptoms?
a. Monitor lab values for an increase in WBCs
b. Administer anti emetics before, during, and after therapy
c. Administer acetaminophen Q4H
d. Monitor vital signs Q4H for 24 hours - ANSWER-a. Monitor lab values for an increase in wbcs
?
Which laboratory value should the nurse review prior to administering the initial dose of a statin
medication?
a. Serum electrolytes
b. Serum liver enzymes
c. Capillary blood glucose
d. Complete blood count - ANSWER-b. Serum liver enzymes
3|Page
, Following a lumbar puncture, the client voices several concerns. Which concern indicates that
the nurse that the client is experiencing a complication of the procedure?
a. "I Feel sick to my stomach and I'm going to throw up"
b. "I'm having pain in my lower back when I move my legs"
c. "My throat hurts badly when I swallow and when I talk"
d. "I have a headache that gets worse when I sit up" - ANSWER-d. "I have a headache that gets
worse when I sit up"
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives
a prescription for Clonidine 0.2 milligrams PO taken twice daily. Which action should the nurse
take?
a. Monitor for signs of bleeding or hemorrhage
b. Compare daily electrolyte levels prior to each morning dose
c. Advice to sit up slowly from a reclining position
d. Administer the medication on an empty stomach - ANSWER-c. Advice to sit up slowly from a
reclining position
A 7 year old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In
obtaining a health history from the child's mother, the recent occurrence of which illness is
most significant?
a. Chicken pox
b. Mumps
c. Sore throat
d. Influenza - ANSWER-c. Sore throat
After placing a 36-week gestation newborn in and isolette and drying the infant with several
blankets, what should the nurse implement next?
4|Page
QUESTIONS AND ANSWERS 100% CORRECT – LATEST 2025
/2026- GRADE A+ GUARANTEED PASS
A client who is admitted with diabetic ketoacidosis is demonstrating Kussmaul breathing and
has a severe headache along with nausea. Her arterial blood gases are: ph 7.50; paco2 30
mmhg; HCO3 24 meq/L. Which assessment finding warrants immediate intervention by the
nurse?
a. Muscle stiffness
b. Abdominal pain
c. Mental stupor
d. Fruity breath - ANSWER-d. Fruity breath
When performing postural drainage on a client with chronic obstructive pulmonary disease,
which approach should the nurse use?
a. Explain that the client may be placed in five positions
b. Instruct the client to breathe shallow and fast
c. Obtain arterial blood gases prior to the procedure
d. Perform the drainage immediately after meals - ANSWER-a. Explain that the client may be
placed in five positions
A young male client with testicular cancer has a living will that describes his desire that no
extraordinary measures be taken to save his life. The health care provider knows the client has a
good prognosis and refuses to write a "do not resuscitate" (DNR) prescription. Which action
should the nurse take?
A. Initiate an Ethics Committee review of the case
B. Place a DNR bracelet on the client's arm
C. Ensure resuscitation equipment is available
1|Page
,D. Ask the family to review options with the client - ANSWER-A. Initiate an Ethics Committee
review of the case
In observing a client's face, which assessment finding requires the most immediate intervention
by the nurse?
a. Cornea are jaundiced
b. Oral mucosa is cyanotic
c. Face is flushed and diaphoretic
d. Eyelids are matted and crusted - ANSWER-b. Oral mucosa is cyanotic
The nurse is assessing a client with cirrhosis and notes that the client has a positive Babinski
reflex. Which action should the nurse take in response to the finding?
a. Ask the client to describe recent alcohol use
b. Keep the clients feet elevated when in bed
c. Assess the clients muscle strength and tone
d. Complete a thorough neurological assessment - ANSWER-d. Complete a thorough
neurological assessment
Which action should the nurse take first after obtaining a urine specimen for culture and
sensitivity from an indwelling urinary catheter?
a. Ensure that the drainage bag is attached to the bed frame
b. Ensure continued sterility of the specimen container
c. Securely fasten the clamp on the drainage bag
d. Label the container with the clients identifiers - ANSWER-c. Securely fasten the clamp on the
drainage bag
?
2|Page
,The home health nurse observes an older client with unilateral weakness place the walker in
front of the chair for support while rising to a standing position. Which action should the nurse
take?
a. Hold the Walker securely to prevent slipping when the client rises
b. Applied gait belt to assist the client to rise out of the chair
c. Instruct the client to use the arms of the chair for support
d. Encourage the client to use the weaker leg with the walker when rising - ANSWER-a. Hold the
walker securely to prevent slipping when the client rises
A client with cancer complains of fever, chills, malaise, and headache following administration
of a colony stimulating factor. Which nursing intervention is most beneficial in helping to reduce
the flu like symptoms?
a. Monitor lab values for an increase in WBCs
b. Administer anti emetics before, during, and after therapy
c. Administer acetaminophen Q4H
d. Monitor vital signs Q4H for 24 hours - ANSWER-a. Monitor lab values for an increase in wbcs
?
Which laboratory value should the nurse review prior to administering the initial dose of a statin
medication?
a. Serum electrolytes
b. Serum liver enzymes
c. Capillary blood glucose
d. Complete blood count - ANSWER-b. Serum liver enzymes
3|Page
, Following a lumbar puncture, the client voices several concerns. Which concern indicates that
the nurse that the client is experiencing a complication of the procedure?
a. "I Feel sick to my stomach and I'm going to throw up"
b. "I'm having pain in my lower back when I move my legs"
c. "My throat hurts badly when I swallow and when I talk"
d. "I have a headache that gets worse when I sit up" - ANSWER-d. "I have a headache that gets
worse when I sit up"
The nurse is caring for a client withdrawing from a fentanyl citrate addiction. The client receives
a prescription for Clonidine 0.2 milligrams PO taken twice daily. Which action should the nurse
take?
a. Monitor for signs of bleeding or hemorrhage
b. Compare daily electrolyte levels prior to each morning dose
c. Advice to sit up slowly from a reclining position
d. Administer the medication on an empty stomach - ANSWER-c. Advice to sit up slowly from a
reclining position
A 7 year old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In
obtaining a health history from the child's mother, the recent occurrence of which illness is
most significant?
a. Chicken pox
b. Mumps
c. Sore throat
d. Influenza - ANSWER-c. Sore throat
After placing a 36-week gestation newborn in and isolette and drying the infant with several
blankets, what should the nurse implement next?
4|Page
