2026 HESI Fundamentals V2
Exam| Actual Exam Questions
and Verified Answers
The nurse observes a newly admitted older adult female take short steps and walk very slowly
while pushing a walker in front of her. What action should the nurse take in response to these
observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
Correct Answer: Complete a full fall risk assessment of the client.
Explanation: Short steps and slow gait with a walker in an older adult indicate increased fall risk.
The priority nursing action is to complete a full fall risk assessment to identify specific risks and
implement appropriate interventions.
A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The
available 2 ml vial is labeled Toradol IM 30 mg/ml. How many should the nurse administer?
(Round to the nearest tenth.)
Correct Answer: 1.5 ml
Explanation: Dose calculation: Desired dose (45 mg) ÷ Concentration (30 mg/ml) = 1.5 ml. The
nurse should administer 1.5 ml.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation
remains at 94%, which is the same reading obtained prior to starting the procedure. What action
should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
,B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth.
Correct Answer: Complete the intermittent suction of the nasopharynx.
Explanation: Oxygen saturation remaining stable at 94% during suctioning indicates the client is
tolerating the procedure without desaturation. The nurse should complete the intermittent
suctioning as planned.
An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert,
oriented, and requests that no heroic measures are implemented if her breathing stops. What
action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care.
Correct Answer: Discuss with the client her meaning of heroic measures.
Explanation: The nurse must first clarify the client's understanding and specific meaning of
"heroic measures" to ensure informed decision-making before proceeding with DNR or other
actions.
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye
drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this
client's teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops."
Correct Answer: "Do not allow the dropper bottle to touch the eye."
Explanation: To prevent contamination and infection, the dropper tip must not touch the eye or
any surface. This is a key safety instruction for eye drop administration.
,When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
Correct Answer: Precipitating factors.
Explanation: Identifying what triggers or precedes the wheezing (e.g., allergens, activity,
position) helps determine the cause and guides targeted interventions for respiratory distress.
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which
client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to
provide routine foot care and file the client's toenails? (Select all that apply.)
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
Correct Answer: Syncope when bending, Hand tremors, and diminished visual acuity.
Explanation: Syncope when bending, hand tremors, and poor vision increase the risk of injury
during nail care. These findings justify delegation to UAP for safety. Urinary incontinence and
shuffling gait do not directly relate to foot/nail care safety.
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client's risk for infection related to the
catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
, D) Secure the drainage bag at bladder level during transport.
Correct Answer: Encourage increased intake of oral fluids.
Explanation: Increased fluid intake promotes urine flow, which helps flush bacteria from the
urinary tract and reduces infection risk with an indwelling catheter.
To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
Correct Answer: Ask the client to describe the pain.
Explanation: Asking the client to describe the pain (e.g., sharp, dull, burning) directly assesses
the quality of pain, which is a key characteristic in pain assessment.
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have
cancer and do not have long to live." Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live"
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
Correct Answer: "Yes, your condition is serious."
Explanation: This response acknowledges the client's statement honestly and therapeutically
without false reassurance or dismissing concerns, opening the door for further discussion.
When performing blood pressure measurement to assess for orthostatic hypotension, which
action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
Exam| Actual Exam Questions
and Verified Answers
The nurse observes a newly admitted older adult female take short steps and walk very slowly
while pushing a walker in front of her. What action should the nurse take in response to these
observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
Correct Answer: Complete a full fall risk assessment of the client.
Explanation: Short steps and slow gait with a walker in an older adult indicate increased fall risk.
The priority nursing action is to complete a full fall risk assessment to identify specific risks and
implement appropriate interventions.
A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The
available 2 ml vial is labeled Toradol IM 30 mg/ml. How many should the nurse administer?
(Round to the nearest tenth.)
Correct Answer: 1.5 ml
Explanation: Dose calculation: Desired dose (45 mg) ÷ Concentration (30 mg/ml) = 1.5 ml. The
nurse should administer 1.5 ml.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation
remains at 94%, which is the same reading obtained prior to starting the procedure. What action
should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
,B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth.
Correct Answer: Complete the intermittent suction of the nasopharynx.
Explanation: Oxygen saturation remaining stable at 94% during suctioning indicates the client is
tolerating the procedure without desaturation. The nurse should complete the intermittent
suctioning as planned.
An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert,
oriented, and requests that no heroic measures are implemented if her breathing stops. What
action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care.
Correct Answer: Discuss with the client her meaning of heroic measures.
Explanation: The nurse must first clarify the client's understanding and specific meaning of
"heroic measures" to ensure informed decision-making before proceeding with DNR or other
actions.
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye
drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this
client's teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops."
Correct Answer: "Do not allow the dropper bottle to touch the eye."
Explanation: To prevent contamination and infection, the dropper tip must not touch the eye or
any surface. This is a key safety instruction for eye drop administration.
,When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
Correct Answer: Precipitating factors.
Explanation: Identifying what triggers or precedes the wheezing (e.g., allergens, activity,
position) helps determine the cause and guides targeted interventions for respiratory distress.
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which
client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to
provide routine foot care and file the client's toenails? (Select all that apply.)
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
Correct Answer: Syncope when bending, Hand tremors, and diminished visual acuity.
Explanation: Syncope when bending, hand tremors, and poor vision increase the risk of injury
during nail care. These findings justify delegation to UAP for safety. Urinary incontinence and
shuffling gait do not directly relate to foot/nail care safety.
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client's risk for infection related to the
catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
, D) Secure the drainage bag at bladder level during transport.
Correct Answer: Encourage increased intake of oral fluids.
Explanation: Increased fluid intake promotes urine flow, which helps flush bacteria from the
urinary tract and reduces infection risk with an indwelling catheter.
To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
Correct Answer: Ask the client to describe the pain.
Explanation: Asking the client to describe the pain (e.g., sharp, dull, burning) directly assesses
the quality of pain, which is a key characteristic in pain assessment.
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have
cancer and do not have long to live." Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live"
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
Correct Answer: "Yes, your condition is serious."
Explanation: This response acknowledges the client's statement honestly and therapeutically
without false reassurance or dismissing concerns, opening the door for further discussion.
When performing blood pressure measurement to assess for orthostatic hypotension, which
action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
