HESI RN FUNDAMENTALS
NEWEST ACTUAL EXAM
VERSION 4 COMPLETE 150
QUESTIONS AND
CORRECT DETAILED
ANSWERS |ALREADY
GRADED A
1. A nurse is caring for a patient with a new colostomy. Which statement
indicates the patient needs more education about colostomy care?
● A. "I will change the colostomy bag once a week."
● B. "I will clean the stoma with water and soap."
● C. "I will check the skin around the stoma for irritation."
● D. "I will empty the colostomy bag when it's one-third full."
Answer: A. "I will change the colostomy bag once a week."
Rationale: The colostomy bag should be changed every 3 to 7 days or sooner if there is
leakage. Changing it once a week may result in skin irritation or infection if there is leakage,
hence this statement indicates a need for more education.
2. A nurse is preparing to administer a medication via a nasogastric (NG)
tube. Which action should the nurse take first?
● A. Verify the placement of the NG tube.
● B. Flush the tube with 30 mL of sterile water.
● C. Crush the medication into a fine powder.
● D. Elevate the head of the bed.
,Answer: A. Verify the placement of the NG tube.
Rationale: The first step is to verify that the NG tube is in the correct position to avoid
complications such as aspiration. This is typically done by aspirating stomach contents and
checking pH or using other methods of verification. Once placement is confirmed, the
medication can be prepared and administered.
3. Which of the following patients is at the highest risk for developing a
pressure ulcer?
● A. A 60-year-old patient who is post-op hip surgery and ambulatory.
● B. A 75-year-old patient with pneumonia and a Braden Scale score of 18.
● C. A 45-year-old patient who is quadriplegic and unable to move independently.
● D. A 50-year-old patient with a sprained ankle.
Answer: C. A 45-year-old patient who is quadriplegic and unable to move independently.
Rationale: Patients who are immobile, such as those who are quadriplegic, are at the highest
risk of developing pressure ulcers because they are unable to reposition themselves, leading to
prolonged pressure on certain areas of the body.
4. Which nursing action is most appropriate when a patient is receiving
oxygen therapy via nasal cannula at 4 L/min?
● A. Apply petroleum jelly to the patient's nares to prevent dryness.
● B. Humidify the oxygen to prevent nasal mucosa from drying.
● C. Secure the tubing tightly around the patient's ears.
● D. Keep the oxygen tubing loose to prevent strangulation.
Answer: B. Humidify the oxygen to prevent nasal mucosa from drying.
Rationale: Oxygen delivered at rates above 3 L/min should be humidified to prevent drying of
the nasal mucosa. Petroleum jelly is contraindicated because it is flammable, and the tubing
should be secured but not too tightly to prevent pressure sores.
5. A nurse is educating a patient about preventing urinary tract infections
(UTIs). Which of the following statements by the patient indicates correct
understanding?
● A. "I should limit my fluid intake to prevent frequent urination."
● B. "I should wipe from back to front after using the bathroom."
● C. "I should urinate before and after sexual activity."
● D. "I should avoid drinking cranberry juice."
,Answer: C. "I should urinate before and after sexual activity."
Rationale: Urinating before and after sexual activity helps to flush bacteria from the urethra,
reducing the risk of a UTI. Increasing fluid intake, wiping front to back, and drinking cranberry
juice are other effective strategies to prevent UTIs.
6. A patient with pneumonia is having difficulty breathing. Which position
should the nurse place the patient in to facilitate lung expansion?
● A. Supine
● B. Prone
● C. High Fowler's
● D. Side-lying
Answer: C. High Fowler's
Rationale: The High Fowler's position (sitting upright at 90 degrees) promotes lung expansion
and facilitates easier breathing, making it ideal for patients with respiratory issues such as
pneumonia.
7. The nurse is conducting discharge teaching for a patient with
hypertension. Which of the following statements made by the patient
indicates a need for further teaching?
● A. "I will check my blood pressure regularly at home."
● B. "I should stop taking my medication once my blood pressure is normal."
● C. "I will reduce my sodium intake as part of my diet."
● D. "I will exercise regularly to help manage my blood pressure."
Answer: B. "I should stop taking my medication once my blood pressure is normal."
Rationale: Patients should continue taking their blood pressure medication as prescribed, even
if their blood pressure returns to normal, to prevent complications. Stopping the medication
without consulting a healthcare provider could lead to uncontrolled hypertension.
8. A nurse is preparing to insert an indwelling urinary catheter in a female
patient. Which step is most important to prevent infection?
● A. Lubricate the catheter before insertion.
● B. Maintain a sterile field during the procedure.
● C. Inflate the balloon with sterile water after insertion.
● D. Use a larger-sized catheter to reduce risk of leakage.
, Answer: B. Maintain a sterile field during the procedure.
Rationale: Maintaining a sterile field is the most important step in preventing infection during
catheter insertion. Any breach in sterility increases the risk of introducing bacteria into the
urinary tract, leading to infection.
9. A patient with a wound infection is prescribed contact isolation
precautions. Which of the following should the nurse implement?
● A. Place the patient in a room with negative air pressure.
● B. Wear an N95 respirator when entering the room.
● C. Don gloves and a gown before entering the room.
● D. Ensure the patient wears a surgical mask during transport.
Answer: C. Don gloves and a gown before entering the room.
Rationale: Contact precautions require the use of gloves and a gown to prevent the spread of
infection through direct contact with the patient or contaminated surfaces. Negative air pressure
and N95 respirators are used for airborne precautions, not contact precautions.
10. A patient asks the nurse about ways to manage chronic constipation.
Which of the following should the nurse recommend?
● A. "Increase your intake of refined carbohydrates."
● B. "Limit fluid intake to 1 liter per day."
● C. "Exercise regularly to promote bowel function."
● D. "Avoid fiber-rich foods, as they can worsen constipation."
Answer: C. "Exercise regularly to promote bowel function."
Rationale: Regular exercise stimulates peristalsis and promotes healthy bowel function. Fiber-
rich foods and increased fluid intake are also helpful in managing constipation, while refined
carbohydrates can contribute to constipation.
11. A patient is admitted with a diagnosis of fluid volume excess. Which
assessment finding should the nurse expect?
● A. Hypotension
● B. Jugular vein distention
● C. Dry mucous membranes
● D. Weight loss
NEWEST ACTUAL EXAM
VERSION 4 COMPLETE 150
QUESTIONS AND
CORRECT DETAILED
ANSWERS |ALREADY
GRADED A
1. A nurse is caring for a patient with a new colostomy. Which statement
indicates the patient needs more education about colostomy care?
● A. "I will change the colostomy bag once a week."
● B. "I will clean the stoma with water and soap."
● C. "I will check the skin around the stoma for irritation."
● D. "I will empty the colostomy bag when it's one-third full."
Answer: A. "I will change the colostomy bag once a week."
Rationale: The colostomy bag should be changed every 3 to 7 days or sooner if there is
leakage. Changing it once a week may result in skin irritation or infection if there is leakage,
hence this statement indicates a need for more education.
2. A nurse is preparing to administer a medication via a nasogastric (NG)
tube. Which action should the nurse take first?
● A. Verify the placement of the NG tube.
● B. Flush the tube with 30 mL of sterile water.
● C. Crush the medication into a fine powder.
● D. Elevate the head of the bed.
,Answer: A. Verify the placement of the NG tube.
Rationale: The first step is to verify that the NG tube is in the correct position to avoid
complications such as aspiration. This is typically done by aspirating stomach contents and
checking pH or using other methods of verification. Once placement is confirmed, the
medication can be prepared and administered.
3. Which of the following patients is at the highest risk for developing a
pressure ulcer?
● A. A 60-year-old patient who is post-op hip surgery and ambulatory.
● B. A 75-year-old patient with pneumonia and a Braden Scale score of 18.
● C. A 45-year-old patient who is quadriplegic and unable to move independently.
● D. A 50-year-old patient with a sprained ankle.
Answer: C. A 45-year-old patient who is quadriplegic and unable to move independently.
Rationale: Patients who are immobile, such as those who are quadriplegic, are at the highest
risk of developing pressure ulcers because they are unable to reposition themselves, leading to
prolonged pressure on certain areas of the body.
4. Which nursing action is most appropriate when a patient is receiving
oxygen therapy via nasal cannula at 4 L/min?
● A. Apply petroleum jelly to the patient's nares to prevent dryness.
● B. Humidify the oxygen to prevent nasal mucosa from drying.
● C. Secure the tubing tightly around the patient's ears.
● D. Keep the oxygen tubing loose to prevent strangulation.
Answer: B. Humidify the oxygen to prevent nasal mucosa from drying.
Rationale: Oxygen delivered at rates above 3 L/min should be humidified to prevent drying of
the nasal mucosa. Petroleum jelly is contraindicated because it is flammable, and the tubing
should be secured but not too tightly to prevent pressure sores.
5. A nurse is educating a patient about preventing urinary tract infections
(UTIs). Which of the following statements by the patient indicates correct
understanding?
● A. "I should limit my fluid intake to prevent frequent urination."
● B. "I should wipe from back to front after using the bathroom."
● C. "I should urinate before and after sexual activity."
● D. "I should avoid drinking cranberry juice."
,Answer: C. "I should urinate before and after sexual activity."
Rationale: Urinating before and after sexual activity helps to flush bacteria from the urethra,
reducing the risk of a UTI. Increasing fluid intake, wiping front to back, and drinking cranberry
juice are other effective strategies to prevent UTIs.
6. A patient with pneumonia is having difficulty breathing. Which position
should the nurse place the patient in to facilitate lung expansion?
● A. Supine
● B. Prone
● C. High Fowler's
● D. Side-lying
Answer: C. High Fowler's
Rationale: The High Fowler's position (sitting upright at 90 degrees) promotes lung expansion
and facilitates easier breathing, making it ideal for patients with respiratory issues such as
pneumonia.
7. The nurse is conducting discharge teaching for a patient with
hypertension. Which of the following statements made by the patient
indicates a need for further teaching?
● A. "I will check my blood pressure regularly at home."
● B. "I should stop taking my medication once my blood pressure is normal."
● C. "I will reduce my sodium intake as part of my diet."
● D. "I will exercise regularly to help manage my blood pressure."
Answer: B. "I should stop taking my medication once my blood pressure is normal."
Rationale: Patients should continue taking their blood pressure medication as prescribed, even
if their blood pressure returns to normal, to prevent complications. Stopping the medication
without consulting a healthcare provider could lead to uncontrolled hypertension.
8. A nurse is preparing to insert an indwelling urinary catheter in a female
patient. Which step is most important to prevent infection?
● A. Lubricate the catheter before insertion.
● B. Maintain a sterile field during the procedure.
● C. Inflate the balloon with sterile water after insertion.
● D. Use a larger-sized catheter to reduce risk of leakage.
, Answer: B. Maintain a sterile field during the procedure.
Rationale: Maintaining a sterile field is the most important step in preventing infection during
catheter insertion. Any breach in sterility increases the risk of introducing bacteria into the
urinary tract, leading to infection.
9. A patient with a wound infection is prescribed contact isolation
precautions. Which of the following should the nurse implement?
● A. Place the patient in a room with negative air pressure.
● B. Wear an N95 respirator when entering the room.
● C. Don gloves and a gown before entering the room.
● D. Ensure the patient wears a surgical mask during transport.
Answer: C. Don gloves and a gown before entering the room.
Rationale: Contact precautions require the use of gloves and a gown to prevent the spread of
infection through direct contact with the patient or contaminated surfaces. Negative air pressure
and N95 respirators are used for airborne precautions, not contact precautions.
10. A patient asks the nurse about ways to manage chronic constipation.
Which of the following should the nurse recommend?
● A. "Increase your intake of refined carbohydrates."
● B. "Limit fluid intake to 1 liter per day."
● C. "Exercise regularly to promote bowel function."
● D. "Avoid fiber-rich foods, as they can worsen constipation."
Answer: C. "Exercise regularly to promote bowel function."
Rationale: Regular exercise stimulates peristalsis and promotes healthy bowel function. Fiber-
rich foods and increased fluid intake are also helpful in managing constipation, while refined
carbohydrates can contribute to constipation.
11. A patient is admitted with a diagnosis of fluid volume excess. Which
assessment finding should the nurse expect?
● A. Hypotension
● B. Jugular vein distention
● C. Dry mucous membranes
● D. Weight loss
