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NURSING HESI FUNDAMENTALS EXAM 2025
UPDATED ACTUAL EXAM WITH CORRECT
SOLUTIONS.
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. - correct 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.
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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. - correct
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.
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C) Teach the client to splint the incision while walking to the
bathroom.
D) Administer an analgesic before the client attempts to
defecate. - correct 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? - correct 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
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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. - correct 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?
NURSING HESI FUNDAMENTALS EXAM 2025
UPDATED ACTUAL EXAM WITH CORRECT
SOLUTIONS.
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. - correct 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.
,2 | Page
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. - correct
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.
,3 | Page
C) Teach the client to splint the incision while walking to the
bathroom.
D) Administer an analgesic before the client attempts to
defecate. - correct 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? - correct 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
, 4 | Page
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. - correct 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?
