HESI Nursing Fundamentals Exam Exit
2024-2025 Questions And Verified
Answers
The nurse removes the dressing on a client's heel that is covering a pressure sore
one-inch in diameter and finds that there is straw-colored drainage seeping from
the wound. What description of this finding should the nurse include in the client's
record?
A) Stage 1 pressure sore draining sero-sanguineous drainage.
B) Pressure sore at bony prominence with exudate noted.
C) One-inch pressure sore draining serous fluid.
D) Pressure sore on heel with a small amount of purulent drainage. - ANSWER-
Answer: C
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate documentation
based on the information provided. Information to stage this pressure score (A) is
not provided, and sero-sanguineous drainage is pale and watery with a combination
of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as
pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating
the presence of dead or living organisms and white blood cells.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy
in the treatment room, he cries continuously. What intervention should the nurse
implement?
,A) Take the child back to his room.
B) Recruit others to restrain the child.
C) Ask the mother to be present to soothe the child.
D) Show the child how to manipulate the equipment. - ANSWER- Answer: C
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities.
The mother's assistance (C) can provide a stabilizing presence to help soothe the
preschooler, who may perceive the invasive procedure as mutilating. To preserve
the child's sense of security associated with the hospital room, it is best to perform
difficult or painful procedures in another area (A). (B) may be necessary to prevent
injury if the child is unable to cooperate with the mother's coaxing. (D) is best done
before going to the treatment room when the child feels less threatened.
On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel
elimination?
A) Remind the client to turn every two hours while lying in bed.
B) Provide warm prune juice before the client goes to bed at night.
C) Teach the client to splint the incision while walking to the bathroom.
D) Administer an analgesic before the client attempts to defecate. - ANSWER-
Answer: B
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune
juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is
less likely to relieve the client's constipation. (C) reduces discomfort during
ambulation, but will not help relieve the client's constipation. Defecation is not
painful following most surgeries, and many analgesics used postoperatively cause
constipation, so (D) is contraindicated.
,To obtain the most complete assessment data for a client with chronic pain, which
information should the nurse obtain?
A) Can you describe where your pain is the most severe?
B) What is your pain intensity on a scale of 1 to 10?
C) Is your pain best described as aching, throbbing, or sharp?
D) Which activities during a routine day are impacted by your pain? - ANSWER-
Answer: D
Rationale
A client with chronic pain is more likely to have adapted physiologically to vital
sign changes, localization or intensity, so pain assessment should focus on any
interference with daily activities (D), such as sleep, relationships with others,
physical activity, and emotional well-being. Exacerbation of acute symptoms, such
as pain distribution, patterns, intensity, and descriptors elicit specific assessment
findings, whereas (A, B, and C) are limiting, closed-end questions, and can be
answered with a yes, no, or a number.
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The nurse
determines that the client has been noncompliant with the diet, based on which
report from the 24-hour dietary recall? (Select all that apply.)
A) Snack of potato chips, and diet soda.
B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C) Breakfast of eggs, bacon, toast, and coffee.
D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E) Bedtime snack of crackers and milk. - ANSWER- Answers: A, C
Rationale
, Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and
crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a
low sodium, low protein diet.
A client provides the nurse with information about the reason for seeking care. The
nurse realizes that some information about past hospitalizations is missing. How
should the nurse obtain this information?
A) Solicit information on hospitalization from the insurance company.
B) Look up previous medical records from archived hospital documents.
C) Ask the client to discuss previous hospitalizations in the last 5 years.
D) Elicit specific facts about past hospitalizations with direct questions. -
ANSWER- Answer: D
Rationale
Direct questions should be used after the client's opening narrative to fill in any
details that have been left out or during the review of systems to elicit specific facts
about past health problems.
An older female client with rheumatoid arthritis is complaining of severe joint pain
that is caused by the weight of the linen on her legs. What action should the nurse
implement first?
A) Apply flannel pajamas to provide warmth.
B) Administer a PRN dose of ibuprofen.
C) Perform range of motion exercises in a warm tub.
D) Drape the sheets over the footboard of the bed. - ANSWER- Answer: D
Rationale
The nurse should first provide an immediate comfort measure to address the
client's complaint about the linens and drape the linens over the footboard of the
2024-2025 Questions And Verified
Answers
The nurse removes the dressing on a client's heel that is covering a pressure sore
one-inch in diameter and finds that there is straw-colored drainage seeping from
the wound. What description of this finding should the nurse include in the client's
record?
A) Stage 1 pressure sore draining sero-sanguineous drainage.
B) Pressure sore at bony prominence with exudate noted.
C) One-inch pressure sore draining serous fluid.
D) Pressure sore on heel with a small amount of purulent drainage. - ANSWER-
Answer: C
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate documentation
based on the information provided. Information to stage this pressure score (A) is
not provided, and sero-sanguineous drainage is pale and watery with a combination
of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as
pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating
the presence of dead or living organisms and white blood cells.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy
in the treatment room, he cries continuously. What intervention should the nurse
implement?
,A) Take the child back to his room.
B) Recruit others to restrain the child.
C) Ask the mother to be present to soothe the child.
D) Show the child how to manipulate the equipment. - ANSWER- Answer: C
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities.
The mother's assistance (C) can provide a stabilizing presence to help soothe the
preschooler, who may perceive the invasive procedure as mutilating. To preserve
the child's sense of security associated with the hospital room, it is best to perform
difficult or painful procedures in another area (A). (B) may be necessary to prevent
injury if the child is unable to cooperate with the mother's coaxing. (D) is best done
before going to the treatment room when the child feels less threatened.
On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel
elimination?
A) Remind the client to turn every two hours while lying in bed.
B) Provide warm prune juice before the client goes to bed at night.
C) Teach the client to splint the incision while walking to the bathroom.
D) Administer an analgesic before the client attempts to defecate. - ANSWER-
Answer: B
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the prune
juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is
less likely to relieve the client's constipation. (C) reduces discomfort during
ambulation, but will not help relieve the client's constipation. Defecation is not
painful following most surgeries, and many analgesics used postoperatively cause
constipation, so (D) is contraindicated.
,To obtain the most complete assessment data for a client with chronic pain, which
information should the nurse obtain?
A) Can you describe where your pain is the most severe?
B) What is your pain intensity on a scale of 1 to 10?
C) Is your pain best described as aching, throbbing, or sharp?
D) Which activities during a routine day are impacted by your pain? - ANSWER-
Answer: D
Rationale
A client with chronic pain is more likely to have adapted physiologically to vital
sign changes, localization or intensity, so pain assessment should focus on any
interference with daily activities (D), such as sleep, relationships with others,
physical activity, and emotional well-being. Exacerbation of acute symptoms, such
as pain distribution, patterns, intensity, and descriptors elicit specific assessment
findings, whereas (A, B, and C) are limiting, closed-end questions, and can be
answered with a yes, no, or a number.
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The nurse
determines that the client has been noncompliant with the diet, based on which
report from the 24-hour dietary recall? (Select all that apply.)
A) Snack of potato chips, and diet soda.
B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C) Breakfast of eggs, bacon, toast, and coffee.
D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E) Bedtime snack of crackers and milk. - ANSWER- Answers: A, C
Rationale
, Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and
crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a
low sodium, low protein diet.
A client provides the nurse with information about the reason for seeking care. The
nurse realizes that some information about past hospitalizations is missing. How
should the nurse obtain this information?
A) Solicit information on hospitalization from the insurance company.
B) Look up previous medical records from archived hospital documents.
C) Ask the client to discuss previous hospitalizations in the last 5 years.
D) Elicit specific facts about past hospitalizations with direct questions. -
ANSWER- Answer: D
Rationale
Direct questions should be used after the client's opening narrative to fill in any
details that have been left out or during the review of systems to elicit specific facts
about past health problems.
An older female client with rheumatoid arthritis is complaining of severe joint pain
that is caused by the weight of the linen on her legs. What action should the nurse
implement first?
A) Apply flannel pajamas to provide warmth.
B) Administer a PRN dose of ibuprofen.
C) Perform range of motion exercises in a warm tub.
D) Drape the sheets over the footboard of the bed. - ANSWER- Answer: D
Rationale
The nurse should first provide an immediate comfort measure to address the
client's complaint about the linens and drape the linens over the footboard of the
