2026 ALL HESI FUNDAMENTALS EXAM SPRING
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CORRECT ANSWERS | TOP TARGET ACADEMIC
GUARANTEED PASS
QUESTION 1
An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes
B. Encourage active range of motion exercises on extremities
C. Position the client on the left side with a pillow between the knees
D. Reposition the client every two hours
Correct Answer: D. Reposition the client every two hours
Rationale: Repositioning the client every two hours is essential to prevent pressure
ulcers and maintain skin integrity. Massaging reddened areas can damage
underlying tissues. Active range of motion on the affected leg is limited.
Positioning on the left side is contraindicated for a fractured left hip.
QUESTION 2
When assessing a client with wrist restraints, the nurse observes that the fingers on
the right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint
B. Apply a pulse oximeter to the right hand
C. Notify the healthcare provider
D. Remove the restraint and assess circulation
Correct Answer: A. Loosen the right wrist restraint
Rationale: The priority nursing action is to restore circulation by loosening the
restraint because blue fingers (cyanosis) indicates decreased circulation. Removing
the restraint and assessing circulation (D) is also important but loosening is the
immediate priority. Pulse oximetry (B) measures hemoglobin with oxygen and is
,not indicated when cyanosis is due to mechanical compression. The healthcare
provider (C) should be notified after immediate action is taken.
QUESTION 3
A client is placed in soft wrist restraints to prevent removal of a nasogastric tube.
Which nursing action is most important?
A. Tie restraints to the bed frame
B. Tie restraints to the side rails
C. Assess skin integrity every 4 hours
D. Remove restraints every 2 hours for ROM exercises
Correct Answer: D. Remove restraints every 2 hours for ROM exercises
Rationale: Restraints should be removed every 2 hours for range of motion
exercises, skin assessment, and toileting. Restraints should be tied to the bed frame
(not side rails) with a quick-release knot. Skin integrity should be assessed more
frequently than every 4 hours.
QUESTION 4
A client with wrist restraints is agitated and trying to remove them. Which
intervention should the nurse implement first?
A. Apply a vest restraint
B. Assess the client's needs (pain, toileting, hunger)
C. Sedate the client with medication
D. Tighten the wrist restraints
Correct Answer: B. Assess the client's needs (pain, toileting, hunger)
Rationale: Agitation may be caused by unmet needs such as pain, hunger, thirst,
or the need to toilet. The nurse should assess and address these needs first.
Applying additional restraints or tightening existing ones may increase agitation.
Sedation should be a last resort.
QUESTION 5
,A client is in four-point restraints. The nurse should assess which of the following
at least every:
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 hours
Correct Answer: A. 15 minutes
Rationale: Clients in restraints should be assessed every 15 minutes for safety,
circulation, and comfort. The nurse must also assess the client's ongoing need for
restraints and document findings.
QUESTION 6
A client is being placed in restraints. Which action should the nurse take to ensure
safety?
A. Apply restraints tightly to prevent movement
B. Tie restraints with a square knot that does not loosen
C. Ensure restraints allow 1-2 finger widths between the restraint and the client's
skin
D. Secure restraints to the side rails
Correct Answer: C. Ensure restraints allow 1-2 finger widths between the
restraint and the client's skin
Rationale: Restraints should be applied so that 1-2 finger widths can be inserted
between the restraint and the client's skin to prevent circulation impairment.
Restraints should be tied with a quick-release knot to the bed frame (not side rails).
QUESTION 7
A client is disoriented and trying to get out of bed. Which intervention should the
nurse implement first?
A. Apply wrist restraints
B. Apply a bed alarm
, C. Place the bed in the lowest position
D. Assign a sitter to stay with the client
Correct Answer: C. Place the bed in the lowest position
Rationale: The priority is to maintain client safety by placing the bed in the lowest
position and keeping the side rails up. A bed alarm and sitter may be used, but the
least restrictive interventions should be implemented first. Restraints are a last
resort.
QUESTION 8
The nurse is caring for a client with a hip fracture who is in traction. Which
nursing action is most important to prevent skin breakdown?
A. Turn the client every 2 hours
B. Massage reddened areas
C. Use a draw sheet to reposition the client
D. Provide a pressure-relieving mattress
Correct Answer: A. Turn the client every 2 hours
Rationale: Regular turning (every 2 hours) is the most important action to prevent
skin breakdown. Massaging reddened areas is contraindicated as it can damage
underlying tissue. A draw sheet and pressure-relieving mattress are adjuncts to
regular repositioning.
SECTION 2: MEDICATION ADMINISTRATION
QUESTION 9
The nurse is administering medications through a nasogastric tube (NGT) while
suction is on. After ensuring correct tube placement, what action should the nurse
take first?
A. Clamp the tube for 20 minutes
B. Flush the tube with water
TEST BANK | LATEST UPDATES | ASSURED
CORRECT ANSWERS | TOP TARGET ACADEMIC
GUARANTEED PASS
QUESTION 1
An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes
B. Encourage active range of motion exercises on extremities
C. Position the client on the left side with a pillow between the knees
D. Reposition the client every two hours
Correct Answer: D. Reposition the client every two hours
Rationale: Repositioning the client every two hours is essential to prevent pressure
ulcers and maintain skin integrity. Massaging reddened areas can damage
underlying tissues. Active range of motion on the affected leg is limited.
Positioning on the left side is contraindicated for a fractured left hip.
QUESTION 2
When assessing a client with wrist restraints, the nurse observes that the fingers on
the right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint
B. Apply a pulse oximeter to the right hand
C. Notify the healthcare provider
D. Remove the restraint and assess circulation
Correct Answer: A. Loosen the right wrist restraint
Rationale: The priority nursing action is to restore circulation by loosening the
restraint because blue fingers (cyanosis) indicates decreased circulation. Removing
the restraint and assessing circulation (D) is also important but loosening is the
immediate priority. Pulse oximetry (B) measures hemoglobin with oxygen and is
,not indicated when cyanosis is due to mechanical compression. The healthcare
provider (C) should be notified after immediate action is taken.
QUESTION 3
A client is placed in soft wrist restraints to prevent removal of a nasogastric tube.
Which nursing action is most important?
A. Tie restraints to the bed frame
B. Tie restraints to the side rails
C. Assess skin integrity every 4 hours
D. Remove restraints every 2 hours for ROM exercises
Correct Answer: D. Remove restraints every 2 hours for ROM exercises
Rationale: Restraints should be removed every 2 hours for range of motion
exercises, skin assessment, and toileting. Restraints should be tied to the bed frame
(not side rails) with a quick-release knot. Skin integrity should be assessed more
frequently than every 4 hours.
QUESTION 4
A client with wrist restraints is agitated and trying to remove them. Which
intervention should the nurse implement first?
A. Apply a vest restraint
B. Assess the client's needs (pain, toileting, hunger)
C. Sedate the client with medication
D. Tighten the wrist restraints
Correct Answer: B. Assess the client's needs (pain, toileting, hunger)
Rationale: Agitation may be caused by unmet needs such as pain, hunger, thirst,
or the need to toilet. The nurse should assess and address these needs first.
Applying additional restraints or tightening existing ones may increase agitation.
Sedation should be a last resort.
QUESTION 5
,A client is in four-point restraints. The nurse should assess which of the following
at least every:
A. 15 minutes
B. 30 minutes
C. 1 hour
D. 2 hours
Correct Answer: A. 15 minutes
Rationale: Clients in restraints should be assessed every 15 minutes for safety,
circulation, and comfort. The nurse must also assess the client's ongoing need for
restraints and document findings.
QUESTION 6
A client is being placed in restraints. Which action should the nurse take to ensure
safety?
A. Apply restraints tightly to prevent movement
B. Tie restraints with a square knot that does not loosen
C. Ensure restraints allow 1-2 finger widths between the restraint and the client's
skin
D. Secure restraints to the side rails
Correct Answer: C. Ensure restraints allow 1-2 finger widths between the
restraint and the client's skin
Rationale: Restraints should be applied so that 1-2 finger widths can be inserted
between the restraint and the client's skin to prevent circulation impairment.
Restraints should be tied with a quick-release knot to the bed frame (not side rails).
QUESTION 7
A client is disoriented and trying to get out of bed. Which intervention should the
nurse implement first?
A. Apply wrist restraints
B. Apply a bed alarm
, C. Place the bed in the lowest position
D. Assign a sitter to stay with the client
Correct Answer: C. Place the bed in the lowest position
Rationale: The priority is to maintain client safety by placing the bed in the lowest
position and keeping the side rails up. A bed alarm and sitter may be used, but the
least restrictive interventions should be implemented first. Restraints are a last
resort.
QUESTION 8
The nurse is caring for a client with a hip fracture who is in traction. Which
nursing action is most important to prevent skin breakdown?
A. Turn the client every 2 hours
B. Massage reddened areas
C. Use a draw sheet to reposition the client
D. Provide a pressure-relieving mattress
Correct Answer: A. Turn the client every 2 hours
Rationale: Regular turning (every 2 hours) is the most important action to prevent
skin breakdown. Massaging reddened areas is contraindicated as it can damage
underlying tissue. A draw sheet and pressure-relieving mattress are adjuncts to
regular repositioning.
SECTION 2: MEDICATION ADMINISTRATION
QUESTION 9
The nurse is administering medications through a nasogastric tube (NGT) while
suction is on. After ensuring correct tube placement, what action should the nurse
take first?
A. Clamp the tube for 20 minutes
B. Flush the tube with water
