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HESI RN STUDY GUIDE 2026 MASTER
SOLUTION DIGEST
◉When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next? A. Record the amount on the client's fluid output record. B. Encourage the client to increase oral fluid intake. C. Notify the health care provider of the findings. D. Palpate the client's bladder for distention.. Answer: A Rationale: The amount and appearance of the client's urine output is within normal limits, so the nurse should record the output, but no additional action is needed.
◉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.
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. If the nurse determines that the client is confused, the surgeon must be notified and permission obtained from the next of kin. ◉When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg.
Rationale: The ANA Scope of Standards of Practice for Psychiatric- Mental Health Nursing serves to direct the philosophy and standards of psychiatric nursing practice. Options A and D define the client's rights. Option B provides ethical guidelines for nursing. ◉The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse consider when administering PN? (Select all that apply.) A. Remove the PN from the refrigerator 30 minutes before infusing. B. Have a second nurse double check the PN before connecting the solution. C. Have a second IV line in place for administering IV medications. D. Assure the infusion time for the PN does not exceed 24 hours. E. Tell the client a feeling of being full should occur with PN. F. Return amber and cloudy solutions of PN to the pharmacy.. Answer: A, D, F Rationale: There are no issues with antibody incompatibility with PN, so there is no need to double check the PN, or start a second IV
line. PN is administered through the venous system and does not satiate the client. The remaining selections are true about the administration of PN. ◉The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion devise for an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What supplies will the nurse take into the room for this procedure? (Select all that apply.) A. A 16 gauge IV catheter B. Normal saline in a 10 mL syringe C. Clear plastic sterile bandage D. Skin preparation antiseptic swab E. 1000 mL bag of normal saline. Answer: B, C, D Rationale: Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old are a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions. A small bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed to start an IV.
C.
"Increase daily intake of water or other oral fluids." D. "Purchase a newer model wheelchair.". Answer: B Rationale: The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client. ◉Which nonverbal action should the nurse implement to demonstrate active listening? A. Sit facing the client. B. Cross arms and legs. C. Avoid eye contact. D. Lean back in the chair.. Answer: A Rationale: Active listening is conveyed using attentive verbal and nonverbal communication techniques. To facilitate therapeutic communication and attentiveness, the nurse should sit facing the
client, which lets the client know that the nurse is there to listen. Active listening skills include postures that are open to the client, such as keeping the arms open and relaxed, not option B, and leaning toward the client, not option D. To communicate involvement and willingness to listen to the client, eye contact should be established and maintained. ◉The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor.. Answer: D Rationale: Option D is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. Option A is important but should be done after the client is in a safe
◉The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts were made prior to obtaining the sample with the tourniquet in place for nearly 5 minutes. Which laboratory finding would the nurse suspect is inaccurate related to the prolonged tourniquet placement? A. Na 148 mEq/L B. K 5.3 mEq/L C. Cl 102 mEq/L D. Ca 9.3 mg/dL. Answer: B Rationale: Prolonged tourniquet placement can cause accumulation of potassium, skewing the result upward. The sodium level is also high, but that is not related to the blood draw. The chloride and calcium levels are normal. ◉The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the nurse bring to the attention of the healthcare provider? A. Temperature: 97.5°F/36.4°C B.
Pulse: 80 beats/min C. Respirations: 26 breaths/min D. Blood pressure: 90/53 mm Hg. Answer: B Rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is below the normal range. The remaining vital signs are within the normal limits for a 1-year-old. ◉The clinic nurse is reviewing an antibiotic medication prescribed to a client with a urinary tract infection. What instructions will the nurse include in the client's teaching? (Select all that apply.) A. Take all of the medication as prescribed, especially when you start feeling better. B. Take the medication with 8 ounce/240 mL of water. C. Call poison control if you start itching, develop hives, or have difficulty breathing. D. Keep this medication out of the reach of small children, preferably in a locked cabinet. E.
Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition. ◉A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings.. Answer: D Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action
should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading. ◉The nurse comes upon an automobile accident involving many cars. Which victim should the nurse see first? A. The victim who is not breathing and does not have a pulse B. The victim who is bleeding out of both the ears, and the nose and mouth, with a blank stare C. The victim who is heavily bleeding bright red blood from a thigh wound D. The victim who is crying, complaining of arm pain, and no other apparent injuries. Answer: C Rationale: The client hemorrhaging from the leg wound is the priority as of the severely injured clients; the nurse can help the client by tying off the leg above the injury and/or applying pressure to the wound site. When there is only one health care provider on the scene, the nurse must provide care to those who are most likely to survive. The client without a pulse and respirations is dead. The
the surgeon. When the nurse signs the consent form, the nurse is witnessing the signature only. ◉In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels.. Answer: A Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety ◉The nurse is preparing an IV solution containing 10 mEq of potassium in 100 mL of normal saline. Which findings would concern the nurse? (Select all that apply.) A. A red and swollen peripheral IV site B.
An order to infuse the solution at 50 mL/hr C. Starting the infusion without an infusion devise D. Inverting the potassium solution every 30 minutes while infusing E. The solution is a lemon-yellow color. Answer: A, C, E Rationale: Potassium can cause phlebitis. The red swollen IV site is showing signs infection. The IV site would need to be changed before starting the solution. Potassium solutions must infuse with an infusion devise to avoid an accidental bolus infusion. Potassium solution should be clear, and not lemon yellow. The remaining selections are not concerning to the nurse. ◉The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? _____ mL (Round to the nearest tenth.) ** 10mg/2mL. Answer: 0. Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL ◉In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible? A.
