Ultimate HESI RN Fundamentals
Study Guide-100 Realistic
Questions&Answers with Rationales
for the 2026-2027 Exam
Cycle//Instant Download Pdf
1. The nurse identifies a potential for infection in a client with
partial-thickness (second-degree) and full-thickness (third-
degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Answer: B
Rationale: Careful handwashing technique is the single most
effective intervention for the prevention of contamination in all
clients. Plasma expanders reverse hypovolemia but do not
decrease infectious organisms. Topical antibacterial creams and
visitor limitations are recommended but are not as proven as
handwashing.
,2. The charge nurse observes a new graduate nurse
demonstrate the administration of two different liquid
medications through a gastrostomy tube used for continuous
feeding. What actions should the nurse take? (Select all that
apply.)
A. Confirm that the nurse determined the amount of gastric
residual
B. Add the liquid volumes when documenting fluid intake
C. Instruct the nurse to administer each medication
separately
D. Flush the tube between medications
Answer: A, B, C
Rationale: Determining gastric residual is important before
administering medications via gastrostomy tube. Liquid
medication volumes should be added to fluid intake
documentation. Medications should be administered separately to
prevent interactions and ensure proper absorption.
3. The nurse educator is conducting a class for unlicensed
assistive personnel (UAP). Which action indicates that a UAP
understands gloving procedures?
A. Puts on new gloves when entering a client's room
B. Wears the same gloves for multiple clients
C. Removes gloves before leaving the client's room
D. Washes gloves between tasks
,Answer: A
Rationale: New gloves should be worn when entering each
client's room to prevent cross-contamination. Gloves are single-
use items and should never be reused or washed.
4. The nurse plans on decreasing the chance of respiratory
compromise for a client. What will the nurse include in this
client's plan of care? (Select all that apply.)
A. Position client in semi-Fowler's position
B. Encourage deep breathing exercises
C. Maintain bed rest at all times
D. Suction as needed
Answer: A, B, D
Rationale: Semi-Fowler's position promotes lung expansion.
Deep breathing exercises help prevent atelectasis. Suctioning
clears airway secretions. Bed rest alone does not decrease
respiratory compromise.
5. A client is undergoing chemotherapy treatment and has a
decreased neutrophil count. What precaution should the
nurse implement?
A. Standard precautions
B. Contact precautions
C. Protective (reverse) isolation
, D. Droplet precautions
Answer: C
Rationale: Clients with low neutrophil counts (neutropenia) are at
increased risk for infection and require protective or reverse
isolation to protect them from pathogens.
6. The nurse notes that a client has cyanosis of the toes and
fingertips. Which vital sign should the nurse obtain first?
A. Blood pressure
B. Temperature
C. Respiratory rate
D. Pulse oximetry
Answer: C
Rationale: Cyanosis indicates poor oxygenation, so respiratory
rate should be assessed first to evaluate breathing status.
7. Which infection control precaution is most appropriate for
a client with tuberculosis?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
Study Guide-100 Realistic
Questions&Answers with Rationales
for the 2026-2027 Exam
Cycle//Instant Download Pdf
1. The nurse identifies a potential for infection in a client with
partial-thickness (second-degree) and full-thickness (third-
degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns
Answer: B
Rationale: Careful handwashing technique is the single most
effective intervention for the prevention of contamination in all
clients. Plasma expanders reverse hypovolemia but do not
decrease infectious organisms. Topical antibacterial creams and
visitor limitations are recommended but are not as proven as
handwashing.
,2. The charge nurse observes a new graduate nurse
demonstrate the administration of two different liquid
medications through a gastrostomy tube used for continuous
feeding. What actions should the nurse take? (Select all that
apply.)
A. Confirm that the nurse determined the amount of gastric
residual
B. Add the liquid volumes when documenting fluid intake
C. Instruct the nurse to administer each medication
separately
D. Flush the tube between medications
Answer: A, B, C
Rationale: Determining gastric residual is important before
administering medications via gastrostomy tube. Liquid
medication volumes should be added to fluid intake
documentation. Medications should be administered separately to
prevent interactions and ensure proper absorption.
3. The nurse educator is conducting a class for unlicensed
assistive personnel (UAP). Which action indicates that a UAP
understands gloving procedures?
A. Puts on new gloves when entering a client's room
B. Wears the same gloves for multiple clients
C. Removes gloves before leaving the client's room
D. Washes gloves between tasks
,Answer: A
Rationale: New gloves should be worn when entering each
client's room to prevent cross-contamination. Gloves are single-
use items and should never be reused or washed.
4. The nurse plans on decreasing the chance of respiratory
compromise for a client. What will the nurse include in this
client's plan of care? (Select all that apply.)
A. Position client in semi-Fowler's position
B. Encourage deep breathing exercises
C. Maintain bed rest at all times
D. Suction as needed
Answer: A, B, D
Rationale: Semi-Fowler's position promotes lung expansion.
Deep breathing exercises help prevent atelectasis. Suctioning
clears airway secretions. Bed rest alone does not decrease
respiratory compromise.
5. A client is undergoing chemotherapy treatment and has a
decreased neutrophil count. What precaution should the
nurse implement?
A. Standard precautions
B. Contact precautions
C. Protective (reverse) isolation
, D. Droplet precautions
Answer: C
Rationale: Clients with low neutrophil counts (neutropenia) are at
increased risk for infection and require protective or reverse
isolation to protect them from pathogens.
6. The nurse notes that a client has cyanosis of the toes and
fingertips. Which vital sign should the nurse obtain first?
A. Blood pressure
B. Temperature
C. Respiratory rate
D. Pulse oximetry
Answer: C
Rationale: Cyanosis indicates poor oxygenation, so respiratory
rate should be assessed first to evaluate breathing status.
7. Which infection control precaution is most appropriate for
a client with tuberculosis?
A. Contact precautions
B. Droplet precautions
C. Airborne precautions
D. Standard precautions
