HESI RN FUNDAMENTALS 2026 UPDATED EXAMS
SCRIPT QUESTIONS AND ANSWERS SURE A+
✔✔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 - ✔✔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.
,✔✔The nurse is instructing a client with cholecystitis regarding diet choices. Which meal
best meets the dietary needs of this client?
A.
Steak, baked beans, and a salad
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake - ✔✔B
Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a
low-fat diet, such as option B. Option A is a high-protein diet, and options C and D
contain high-fat foods, which are contraindicated for this client.
✔✔A 65-year-old client who attends an adult daycare program and is wheelchair mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." - ✔✔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. - ✔✔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. - ✔✔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 position. Because the client is not supporting
himself, option B is impractical. Option C is likely to cause chaos on the unit and might
alarm the other clients.
✔✔The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is
128 mEq/L. The nurse should be alert for which findings? (Select all that apply.)
A.
Weakness in the hands and feet
B.
+1 reflexes to the patella
C.
Headache
D.
Muscle twitching
E.
Nausea
F.
Facial redness - ✔✔A, B, C, E
Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle
twitching and facial redness.
✔✔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 - ✔✔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 - ✔✔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.
Call your healthcare provider (HCP) when your symptoms subside. - ✔✔A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics.
The client needs to take the full course of antibiotics to achieve the maximum effect.
Drinking a glass of water will help keep the body hydrated. All medication should be
kept out of reach, preferably in a locked cabinet. The client needs to call the health care
provider in the event of an allergic reaction to the antibiotic. The medication is
prescribed to treat the infection. There is no need to notify the HCP when the
medication is having the desired effects.
SCRIPT QUESTIONS AND ANSWERS SURE A+
✔✔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 - ✔✔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.
,✔✔The nurse is instructing a client with cholecystitis regarding diet choices. Which meal
best meets the dietary needs of this client?
A.
Steak, baked beans, and a salad
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake - ✔✔B
Rationale: Clients with cholecystitis (inflammation of the gallbladder) should follow a
low-fat diet, such as option B. Option A is a high-protein diet, and options C and D
contain high-fat foods, which are contraindicated for this client.
✔✔A 65-year-old client who attends an adult daycare program and is wheelchair mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair." - ✔✔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. - ✔✔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. - ✔✔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 position. Because the client is not supporting
himself, option B is impractical. Option C is likely to cause chaos on the unit and might
alarm the other clients.
✔✔The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is
128 mEq/L. The nurse should be alert for which findings? (Select all that apply.)
A.
Weakness in the hands and feet
B.
+1 reflexes to the patella
C.
Headache
D.
Muscle twitching
E.
Nausea
F.
Facial redness - ✔✔A, B, C, E
Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle
twitching and facial redness.
✔✔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 - ✔✔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 - ✔✔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.
Call your healthcare provider (HCP) when your symptoms subside. - ✔✔A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics.
The client needs to take the full course of antibiotics to achieve the maximum effect.
Drinking a glass of water will help keep the body hydrated. All medication should be
kept out of reach, preferably in a locked cabinet. The client needs to call the health care
provider in the event of an allergic reaction to the antibiotic. The medication is
prescribed to treat the infection. There is no need to notify the HCP when the
medication is having the desired effects.
