Nursing HESI Fundamentals Assignment Exam Newest with verified
and rationalized answers 2024-2025
1. C (The nursing process is a problem-solving approach that provides an organized, systematic,
decision making process to effectively address the client's needs and problems. The nursing process
includes an organized frame work using knowledge, judgments, and actions by the nurse as the
client's plan of care is determined, and encompasses assessment, analysis, planning, imple
mentation, and evaluation of client care
(C). (A, B, and D) do not support the basis for using the nursing process.
Correct Answer: C)
What is the rationale for using the nursing process in planning care
for clients?
A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems.
B. To establish nursing theory that incorporates the biopsy chosocial nature of humans.
C. As a tool to organize thinking and clinical decision making about clients' healthcare needs.
D. To promote the management of client care in collaboration with other healthcare professionals.
2. In the nursing process, the evaluation component examines the effectiveness of nursing
interventions in achieving client outcomes (D).
(A) is an evaluation of client satisfaction, not outcomes.
(B) is a written record of the plan of care. Although
(C) may occur when client out comes are achieved, evaluation is best determined by attainment of
measurable client outcomes.
Correct Answer: D
What activity should the nurse use in the evaluation phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been alleviated.
D. Examine the effectiveness of nursing interventions toward meeting client outcomes.
,3. The first part of the nursing diagnosis statement is followed by related to the cause, which should
direct the nurse to the appropri ate interventions.
(D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause,
but (D) focuses on the client's response, which the nurse can provide support, reflection and
dialogue
Which statement is an example of a correctly written nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test results.
Correct answer D
4. Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in
others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates cul
turally sensitive care. (B, C, and D) do not demonstrate cultural awareness.
Correct Answer: A
What action by the nurse demonstrates culturally sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and cultural folk remedies.
D. Applies knowledge of a cultural group unless a client embraces Western customs.
5. Acknowledging a client's beliefs and customs related to sickness and healthcare are valuable
components in the plan of care that prevents conflict between the goals of nursing and the client's
cultural practices. Cultural sensitivity begins with examining one's own cultural
values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the
family's needs to care for the client and are not the best ways to cope with the nurse's frustration.
Although (D) may be an option, examining one's cultural differences allows the nurse to
cope,empathize, and implement culturally specific interventions pertaining to the needs of the client
and the family.
Correct Answer: B
,A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care
of a hospitalized client. What action should the nurse im plement to cope with these feelings
offrustration?
A. Suggest that other cultural practices be substituted by the family members.
B. Examine one's own culturally based values, beliefs, attitudes, and practices.
C. Explain to the family that multiple visitors are exhausting to the client.
D. Allow the situation to continue until a family member's action may harm the client.
6. The most important factor in performing a physical assessment is following a consistent and
systematic technique (C) each time an assessment is performed to minimize variation in sequence
which may increase the likelihood of omitting a step or exam of an isolated area. The method of
completing a physical assessment (A, B, and D) may be at the dicretion of the examiner, but a
consistent sequence by the examiner provides a reliable method to ensure thorough re view of the
clients' history, complaints, or body systems.
Correct Answer: C
Which technique is most important for the nurse to implement when performing a physical as
sessment?
A. A head-to-toe approach.
B. The medical systems model.
C. A consistent, systematic ap proach.
D. An approach related to a nursing model.
7. A client's dietary habits should be determined first by the client's dietary recall
(B) before suggesting protein sources or supplements (A and C) as optionsin the client's diet.
Although grains andlegumes (D) contain incomplete proteins that reduces the essential amino acid
pools inside the cells, the client's cultural preferences should be illicited after confirming the client's
dietary history.
Correct Answer: B
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein
malnutrition. What information should the nurse obtain first?
A. Amount of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
, C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client.
8. The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage,
and/or seek out help to maintain health, and is best exempli fied in the client belief or
understanding about diet and health maintenance (D).(A) indicates noncompliance with an action to
be done in the management of diabetes. (B) represents inattentiveness.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
A. Does not check capillary blood
glucose as directed.
B. Occasionally forgets to take daily prescribed medication
(C) reflects knowledge deficit.
Correct Answer: D
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in health.
9. An objective should contain four ele ments: who will perform the activity or
acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under
which the behavior is to be demonstrated, and the specific criteria to be used to measure success.
(C) is a concise statement that is a learning objective that defines exactly how the client will
demonstrate mastery of the content.
(A, B, and D) lack one or more of these elements.
Correct Answer: C
Which statement correctly identifies a written learning objective for a client with peripheral vascular
disease?
A. The nurse will provide client instruction for daily foot care.
B. The client will demonstrate proper trimming toenail technique.
C. Upon discharge, the client will list three ways to protect the feet from injury.
D. After instruction, the nurse will ensure the client understands foot care rationale.
and rationalized answers 2024-2025
1. C (The nursing process is a problem-solving approach that provides an organized, systematic,
decision making process to effectively address the client's needs and problems. The nursing process
includes an organized frame work using knowledge, judgments, and actions by the nurse as the
client's plan of care is determined, and encompasses assessment, analysis, planning, imple
mentation, and evaluation of client care
(C). (A, B, and D) do not support the basis for using the nursing process.
Correct Answer: C)
What is the rationale for using the nursing process in planning care
for clients?
A. As a scientific process to identify nursing diagnoses of a clients' healthcare problems.
B. To establish nursing theory that incorporates the biopsy chosocial nature of humans.
C. As a tool to organize thinking and clinical decision making about clients' healthcare needs.
D. To promote the management of client care in collaboration with other healthcare professionals.
2. In the nursing process, the evaluation component examines the effectiveness of nursing
interventions in achieving client outcomes (D).
(A) is an evaluation of client satisfaction, not outcomes.
(B) is a written record of the plan of care. Although
(C) may occur when client out comes are achieved, evaluation is best determined by attainment of
measurable client outcomes.
Correct Answer: D
What activity should the nurse use in the evaluation phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been alleviated.
D. Examine the effectiveness of nursing interventions toward meeting client outcomes.
,3. The first part of the nursing diagnosis statement is followed by related to the cause, which should
direct the nurse to the appropri ate interventions.
(D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause,
but (D) focuses on the client's response, which the nurse can provide support, reflection and
dialogue
Which statement is an example of a correctly written nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test results.
Correct answer D
4. Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in
others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates cul
turally sensitive care. (B, C, and D) do not demonstrate cultural awareness.
Correct Answer: A
What action by the nurse demonstrates culturally sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and cultural folk remedies.
D. Applies knowledge of a cultural group unless a client embraces Western customs.
5. Acknowledging a client's beliefs and customs related to sickness and healthcare are valuable
components in the plan of care that prevents conflict between the goals of nursing and the client's
cultural practices. Cultural sensitivity begins with examining one's own cultural
values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the
family's needs to care for the client and are not the best ways to cope with the nurse's frustration.
Although (D) may be an option, examining one's cultural differences allows the nurse to
cope,empathize, and implement culturally specific interventions pertaining to the needs of the client
and the family.
Correct Answer: B
,A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care
of a hospitalized client. What action should the nurse im plement to cope with these feelings
offrustration?
A. Suggest that other cultural practices be substituted by the family members.
B. Examine one's own culturally based values, beliefs, attitudes, and practices.
C. Explain to the family that multiple visitors are exhausting to the client.
D. Allow the situation to continue until a family member's action may harm the client.
6. The most important factor in performing a physical assessment is following a consistent and
systematic technique (C) each time an assessment is performed to minimize variation in sequence
which may increase the likelihood of omitting a step or exam of an isolated area. The method of
completing a physical assessment (A, B, and D) may be at the dicretion of the examiner, but a
consistent sequence by the examiner provides a reliable method to ensure thorough re view of the
clients' history, complaints, or body systems.
Correct Answer: C
Which technique is most important for the nurse to implement when performing a physical as
sessment?
A. A head-to-toe approach.
B. The medical systems model.
C. A consistent, systematic ap proach.
D. An approach related to a nursing model.
7. A client's dietary habits should be determined first by the client's dietary recall
(B) before suggesting protein sources or supplements (A and C) as optionsin the client's diet.
Although grains andlegumes (D) contain incomplete proteins that reduces the essential amino acid
pools inside the cells, the client's cultural preferences should be illicited after confirming the client's
dietary history.
Correct Answer: B
A 73-year-old Hispanic client is seen at the community health clinic with a history of protein
malnutrition. What information should the nurse obtain first?
A. Amount of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
, C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client.
8. The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage,
and/or seek out help to maintain health, and is best exempli fied in the client belief or
understanding about diet and health maintenance (D).(A) indicates noncompliance with an action to
be done in the management of diabetes. (B) represents inattentiveness.
The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis?
A. Does not check capillary blood
glucose as directed.
B. Occasionally forgets to take daily prescribed medication
(C) reflects knowledge deficit.
Correct Answer: D
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in health.
9. An objective should contain four ele ments: who will perform the activity or
acquire the desired behavior, the actual behavior that the learner will exhibit, the condition under
which the behavior is to be demonstrated, and the specific criteria to be used to measure success.
(C) is a concise statement that is a learning objective that defines exactly how the client will
demonstrate mastery of the content.
(A, B, and D) lack one or more of these elements.
Correct Answer: C
Which statement correctly identifies a written learning objective for a client with peripheral vascular
disease?
A. The nurse will provide client instruction for daily foot care.
B. The client will demonstrate proper trimming toenail technique.
C. Upon discharge, the client will list three ways to protect the feet from injury.
D. After instruction, the nurse will ensure the client understands foot care rationale.
