HESI Fundamentals Exam Test
Bank
Questions with Verified Answers &
Rationales
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 laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
Answer: D. Gently lift the client when moving into a desired
position.
Rationale: To avoid shearing forces when repositioning, the client
should be lifted gently across a surface (D). Reddened areas should
not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range
of motion (B) may be limited on the affected leg. The position
described in (C) is contraindicated for a client with a fractured left
hip.
2. The nurse is administering medications through a
nasogastric tube (NGT) which is connected to suction. After
ensuring correct tube placement, what action should the
nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
Answer: B. Flush the tube with water.
Rationale: The NGT should be flushed before, after and in between
each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and
D) may be implemented only after the tubing has been flushed.
1
,3. A client who is in hospice care complains of increasing
amounts of pain. The healthcare provider prescribes an
analgesic every four hours as needed. Which action should
the nurse implement?
A. Give an around-the-clock schedule for administration of
analgesics.
B. Administer analgesic medication as needed when the pain is
severe.
C. Provide medication to keep the client sedated and unaware of
stimuli.
D. Offer a medication-free period so that the client can do daily
activities.
Answer: A. Give an around-the-clock schedule for
administration of analgesics.
Rationale: The most effective management of pain is achieved
using an around-the-clock schedule that provides analgesic
medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an
analgesic medication should be administered before the client's pain
peaks (B). Providing comfort is a priority for the client who is dying,
but sedation that impairs the client's ability to interact and
experience the time before life ends should be minimized (C).
Offering a medication-free period allows the serum drug level to fall,
which is not an effective method to manage chronic pain (D).
4. 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. Compare hand color bilaterally.
D. Palpate the right radial pulse.
Answer: A. Loosen the right wrist restraint.
Rationale: The priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry (B)
measures the saturation of hemoglobin with oxygen and is not
indicated in situations where the cyanosis is related to mechanical
compression (the restraints).
2
,5. The nurse is assessing the nutritional status of several
clients. Which client has the greatest nutritional need for
additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
Answer: B. A lactating woman nursing her 3-day-old infant.
Rationale: A lactating woman (B) has the greatest need for
additional protein intake. (A, C, and D) are all conditions that require
protein, but do not have the increased metabolic protein demands
of lactation.
6. A client is in the radiology department at 0900 when the
prescription levofloxacin (Levaquin) 500 mg IV q24h is
scheduled to be administered. The client returns to the unit
at 1300. What is the best intervention for the nurse to
implement?
A. Contact the healthcare provider and complete a medication
variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule
in the morning.
C. Notify the charge nurse and complete an incident report to
explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
Answer: D. Give the missed dose at 1300 and change the
schedule to administer daily at 1300.
Rationale: To ensure that a therapeutic level of medication is
maintained, the nurse should administer the missed dose as soon as
possible, and revise the administration schedule accordingly (D).
The nurse should document the reason for the late dose, but (A and
C) are not warranted. (B) could result in increased blood levels of
the drug.
7. While instructing a male client's wife in the performance
of passive range-of-motion exercises to his contracted
shoulder, the nurse observes that she is holding his arm
3
, above and below the elbow. What nursing action should the
nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better
support.
D. Instruct her to grip directly over the joint for better motion.
Answer: A. Acknowledge that she is supporting the arm
correctly.
Rationale: The wife is performing the passive ROM correctly,
therefore the nurse should acknowledge this fact (A). The joint that
is being exercised should be uncovered (B) while the rest of the
body should remain covered for warmth and privacy. (C and D) do
not provide adequate support to the joint while still allowing for joint
movement.
8. What is the most important reason for starting
intravenous infusions in the upper extremities rather than
the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a
thrombosis.
C. A cannulated extremity is more difficult to move when the leg or
foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more
painful procedure.
Answer: B. A decreased flow rate could result in the
formation of a thrombosis.
Rationale: Venous return is usually better in the upper extremities.
Cannulation of the veins in the lower extremities increases the risk
of thrombus formation (B) which, if dislodged, could be life-
threatening. Superficial veins are often very easy (A) to find in the
feet and legs. Handling a leg or foot with an IV (C) is probably not
any more difficult than handling an arm or hand. Even if the nurse
did believe moving a cannulated leg was more difficult, this is not
the most important reason for using the upper extremities. Pain (D)
is not a consideration.
9. The nurse observes an unlicensed assistive personnel
(UAP) taking a client's blood pressure with a cuff that is too
small, but the blood pressure reading obtained is within the
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Bank
Questions with Verified Answers &
Rationales
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 laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
Answer: D. Gently lift the client when moving into a desired
position.
Rationale: To avoid shearing forces when repositioning, the client
should be lifted gently across a surface (D). Reddened areas should
not be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active range
of motion (B) may be limited on the affected leg. The position
described in (C) is contraindicated for a client with a fractured left
hip.
2. The nurse is administering medications through a
nasogastric tube (NGT) which is connected to suction. After
ensuring correct tube placement, what action should the
nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
Answer: B. Flush the tube with water.
Rationale: The NGT should be flushed before, after and in between
each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and
D) may be implemented only after the tubing has been flushed.
1
,3. A client who is in hospice care complains of increasing
amounts of pain. The healthcare provider prescribes an
analgesic every four hours as needed. Which action should
the nurse implement?
A. Give an around-the-clock schedule for administration of
analgesics.
B. Administer analgesic medication as needed when the pain is
severe.
C. Provide medication to keep the client sedated and unaware of
stimuli.
D. Offer a medication-free period so that the client can do daily
activities.
Answer: A. Give an around-the-clock schedule for
administration of analgesics.
Rationale: The most effective management of pain is achieved
using an around-the-clock schedule that provides analgesic
medications on a regular basis (A) and in a timely manner.
Analgesics are less effective if pain persists until it is severe, so an
analgesic medication should be administered before the client's pain
peaks (B). Providing comfort is a priority for the client who is dying,
but sedation that impairs the client's ability to interact and
experience the time before life ends should be minimized (C).
Offering a medication-free period allows the serum drug level to fall,
which is not an effective method to manage chronic pain (D).
4. 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. Compare hand color bilaterally.
D. Palpate the right radial pulse.
Answer: A. Loosen the right wrist restraint.
Rationale: The priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry (B)
measures the saturation of hemoglobin with oxygen and is not
indicated in situations where the cyanosis is related to mechanical
compression (the restraints).
2
,5. The nurse is assessing the nutritional status of several
clients. Which client has the greatest nutritional need for
additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
Answer: B. A lactating woman nursing her 3-day-old infant.
Rationale: A lactating woman (B) has the greatest need for
additional protein intake. (A, C, and D) are all conditions that require
protein, but do not have the increased metabolic protein demands
of lactation.
6. A client is in the radiology department at 0900 when the
prescription levofloxacin (Levaquin) 500 mg IV q24h is
scheduled to be administered. The client returns to the unit
at 1300. What is the best intervention for the nurse to
implement?
A. Contact the healthcare provider and complete a medication
variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule
in the morning.
C. Notify the charge nurse and complete an incident report to
explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to
administer daily at 1300.
Answer: D. Give the missed dose at 1300 and change the
schedule to administer daily at 1300.
Rationale: To ensure that a therapeutic level of medication is
maintained, the nurse should administer the missed dose as soon as
possible, and revise the administration schedule accordingly (D).
The nurse should document the reason for the late dose, but (A and
C) are not warranted. (B) could result in increased blood levels of
the drug.
7. While instructing a male client's wife in the performance
of passive range-of-motion exercises to his contracted
shoulder, the nurse observes that she is holding his arm
3
, above and below the elbow. What nursing action should the
nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better
support.
D. Instruct her to grip directly over the joint for better motion.
Answer: A. Acknowledge that she is supporting the arm
correctly.
Rationale: The wife is performing the passive ROM correctly,
therefore the nurse should acknowledge this fact (A). The joint that
is being exercised should be uncovered (B) while the rest of the
body should remain covered for warmth and privacy. (C and D) do
not provide adequate support to the joint while still allowing for joint
movement.
8. What is the most important reason for starting
intravenous infusions in the upper extremities rather than
the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a
thrombosis.
C. A cannulated extremity is more difficult to move when the leg or
foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more
painful procedure.
Answer: B. A decreased flow rate could result in the
formation of a thrombosis.
Rationale: Venous return is usually better in the upper extremities.
Cannulation of the veins in the lower extremities increases the risk
of thrombus formation (B) which, if dislodged, could be life-
threatening. Superficial veins are often very easy (A) to find in the
feet and legs. Handling a leg or foot with an IV (C) is probably not
any more difficult than handling an arm or hand. Even if the nurse
did believe moving a cannulated leg was more difficult, this is not
the most important reason for using the upper extremities. Pain (D)
is not a consideration.
9. The nurse observes an unlicensed assistive personnel
(UAP) taking a client's blood pressure with a cuff that is too
small, but the blood pressure reading obtained is within the
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