HESI - FUNDAMENTALS PRACTICE
QUESTIONS
When44turning44an44immobile44bedridden44client44without44assistance,44which44action44b
y44the44nurse44best44ensures44client44safety?
A.44Securely44grasp44the44client's44arm44and44leg.
B.44Put44bed44rails44up44on44the44side44of44bed44opposite44from44the44nurse.
C.44Correctly44position44and44use44a44turn44sheet.
D.44Lower44the44head44of44the44client's44bed44slowly.44-44answer--B
Rationale:44Because44the44nurse44can44only44stand44on44one44side44of44the44bed,44bed4
4rails44should44be44up44on44the44opposite44side44to44ensure44that44the44client44does44not
44fall44out44of44bed.44Option44A44can44cause44client44injury44to44the44skin44or44joint.44Opti
ons44C44and44D44are44useful44techniques44while44turning44a44client44but44have44less44pri
ority44in44terms44of44safety44than44use44of44the44bed44rails.
The44nurse44identifies44a44potential44for44infection44in44a44client44with44partial-
thickness44(second-degree)44and44full-thickness44(third-
degree)44burns.44What44intervention44has44the44highest44priority44in44decreasing44the44cl
ient's44risk44of44infection?
A.44Administration44of44plasma44expanders
B.44Use44of44careful44handwashing44technique
C.44Application44of44a44topical44antibacterial44cream
D.44Limiting44visitors44to44the44client44with44burns44-44answer--B
Rationale:44Careful44handwashing44technique44is44the44single44most44effective44interven
tion44for44the44prevention44of44contamination44to44all44clients.44Option44A44reverses44the4
4hypovolemia44that44initially44accompanies44burn44trauma44but44is44not44related44to44dec
reasing44the44proliferation44of44infective44organisms.44Options44C44and44D44are44recom
mended44by44various44burn44centers44as44possible44ways44to44reduce44the44chance44of4
4infection.44Option44B44is44a44proven44technique44to44prevent44infection.
The44nurse44is44aware44that44malnutrition44is44a44common44problem44among44clients44s
erved44by44a44community44health44clinic44for44the44homeless.44Which44laboratory44value
44is44the44most44reliable44indicator44of44chronic44protein44malnutrition?
A.44Low44serum44albumin44level
B.44Low44serum44transferrin44level
,C.44High44hemoglobin44level
D.44High44cholesterol44level44-44answer--A
Rationale:44Long-
term44protein44deficiency44is44required44to44cause44significantly44lowered44serum44album
in44levels.44Albumin44is44made44by44the44liver44only44when44adequate44amounts44of44am
ino44acids44(from44protein44breakdown)44are44available.44Albumin44has44a44long44half-
life,44so44acute44protein44loss44does44not44significantly44alter44serum44levels.44Option44B
44is44a44serum44protein44with44a44half-
life44of44only44844to441044days,44so44it44will44drop44with44an44acute44protein44deficiency.44
Options44C44and44D44are44not44clinical44measures44of44protein44malnutrition.
In44completing44a44client's44preoperative44routine,44the44nurse44finds44that44the44operativ
e44permit44is44not44signed.44The44client44begins44to44ask44more44questions44about44the44
surgical44procedure.44Which44action44should44the44nurse44take44next?
A.44Witness44the44client's44signature44to44the44permit.
B.44Answer44the44client's44questions44about44the44surgery.
C.44Inform44the44surgeon44that44the44operative44permit44is44not44signed44and44the44client
44has44questions44about44the44surgery.
D.44Reassure44the44client44that44the44surgeon44will44answer44any44questions44before44th
e44anesthesia44is44administered.44-44answer--C
Rationale:44The44surgeon44should44be44informed44immediately44that44the44permit44is44no
t44signed.44It44is44the44surgeon's44responsibility44to44explain44the44procedure44to44the44cli
ent44and44obtain44the44client's44signature44on44the44permit.44Although44the44nurse44can44
witness44an44operative44permit,44the44procedure44must44first44be44explained44by44the44h
ealth44care44provider44or44surgeon,44including44answering44the44client's44questions.44Th
e44client's44questions44should44be44addressed44before44the44permit44is44signed.
The44nurse44is44assessing44several44clients44prior44to44surgery.44Which44factor44in44a44cl
ient's44history44poses44the44greatest44threat44for44complications44to44occur44during44surg
ery?
A.44Taking44birth44control44pills44for44the44past44244years
B.44Taking44anticoagulants44for44the44past44year
C.44Recently44completing44antibiotic44therapy
D.44Having44taken44laxatives44PRN44for44the44last44644months44-44answer--B
Rationale:
Anticoagulants44increase44the44risk44for44bleeding44during44surgery,44which44can44pose4
4a44threat44for44the44development44of44surgical44complications.44The44health44care44prov
ider44should44be44informed44that44the44client44is44taking44these44drugs.44Although44client
s44who44take44birth44control44pills44may44be44more44susceptible44to44the44development44
of44thrombi,44such44problems44usually44occur44postoperatively.44A44client44with44option44
C44or44D44is44at44less44of44a44surgical44risk44than44with44option44B.
When44assisting44a44client44from44the44bed44to44a44chair,44which44procedure44is44best44f
or44the44nurse44to44follow?
A.44Place44the44chair44parallel44to44the44bed,44with44its44back44toward44the44head44of44th
e44bed44and44assist44the44client44in44moving44to44the44chair.
,B.44With44the44nurse's44feet44spread44apart44and44knees44aligned44with44the44client's44kn
ees,44stand44and44pivot44the44client44into44the44chair.
C.44Assist44the44client44to44a44standing44position44by44gently44lifting44upward,44undernea
th44the44axillae.
D.44Stand44beside44the44client,44place44the44client's44arms44around44the44nurse's44neck,4
4and44gently44move44the44client44to44the44chair.44-44answer--B
Rationale:44Option44B44describes44the44correct44positioning44of44the44nurse44and44afford
s44the44nurse44a44wide44base44of44support44while44stabilizing44the44client's44knees44whe
n44assisting44to44a44standing44position.44The44chair44should44be44placed44at44a4445-
degree44angle44to44the44bed,44with44the44back44of44the44chair44toward44the44head44of44th
e44bed.44Clients44should44never44be44lifted44under44the44axillae;44this44could44damage44
nerves44and44strain44the44nurse's44back.44The44client44should44be44instructed44to44use44t
he44arms44of44the44chair44and44should44never44place44his44or44her44arms44around44the44
nurse's44neck;44this44places44undue44stress44on44the44nurse's44neck44and44back44and44i
ncreases44the44risk44for44a44fall.
Which44step(s)44should44the44nurse44take44when44administering44ear44drops44to44an44ad
ult44client?44(Select44all44that44apply.)
A.44Place44the44client44in44a44side-lying44position.
B.44Pull44the44auricle44upward44and44outward.
C.44Hold44the44dropper44644cm44above44the44ear44canal.
D.44Place44a44cotton44ball44into44the44inner44canal.
E.44Pull44the44auricle44down44and44back.44-44answer--A,44B
Rationale:44The44correct44answers44(A44and44B)44are44the44appropriate44administration44
of44ear44drops.44The44dropper44should44be44held44144cm44(½44inch)44above44the44ear44c
anal44(C).44A44cotton44ball44should44be44placed44in44the44outermost44canal44(D).44The44a
uricle44is44pulled44down44and44back44for44a44child44younger44than44344years44of44age,44b
ut44not44an44adult44(E).
The44nurse44is44instructing44a44client44in44the44proper44use44of44a44metered-
dose44inhaler.44Which44instruction44should44the44nurse44provide44the44client44to44ensure
44the44optimal44benefits44from44the44drug?
A.44"Fill44your44lungs44with44air44through44your44mouth44and44then44compress44the44inha
ler."
B.44"Compress44the44inhaler44while44slowly44breathing44in44through44your44mouth."
C.44"Compress44the44inhaler44while44inhaling44quickly44through44your44nose."
D.44"Exhale44completely44after44compressing44the44inhaler44and44then44inhale."44-
44answer--B
Rationale:44The44medication44should44be44inhaled44through44the44mouth44simultaneousl
y44with44compression44of44the44inhaler.44This44will44facilitate44the44desired44destination44
of44the44aerosol44medication44deep44in44the44lungs44for44an44optimal44bronchodilation44e
ffect.44Options44A,44C,44and44D44do44not44allow44for44deep44lung44penetration.
A4420-year-
old44female44client44with44a44noticeable44body44odor44has44refused44to44shower44for44the
, 44last44344days.44She44states,44"I44have44been44told44that44it44is44harmful44to44bathe44duri
ng44my44period."44Which44action44should44the44nurse44take44first?
A.44Accept44and44document44the44client's44wish44to44refrain44from44bathing.
B.44Offer44to44give44the44client44a44bed44bath,44avoiding44the44perineal44area.
C.44Obtain44written44brochures44about44menstruation44to44give44to44the44client.
D.44Teach44the44importance44of44personal44hygiene44during44menstruation44with44the44cl
ient.44-44answer--D
Rationale:44Because44a44shower44is44most44beneficial44for44the44client44in44terms44of44hy
giene,44the44client44should44receive44teaching44first,44respecting44any44personal44beliefs
44such44as44cultural44or44spiritual44values.44After44client44teaching,44the44client44may44stil
l44choose44option44A44or44B.44Brochures44reinforce44the44teaching.
While44reviewing44the44side44effects44of44a44newly44prescribed44medication,44a4472-
year-
old44client44notes44that44one44of44the44side44effects44is44a44reduction44in44sexual44drive.4
4Which44is44the44best44response44by44the44nurse?
A.44"How44will44this44affect44your44present44sexual44activity?"
B.44"How44active44is44your44current44sex44life?"
C.44"How44has44your44sex44life44changed44as44you44have44become44older?"
D.44"Tell44me44about44your44sexual44needs44as44an44older44adult."44-44answer--A
Rationale:44Option44A44offers44an44open-
ended44question44most44relevant44to44the44client's44statement.44Option44B44does44not44o
ffer44the44client44the44opportunity44to44express44concerns.44Options44C44and44D44are44ev
en44less44relevant44to44the44client's44statement.
The44nurse44is44using44the44Glasgow44Coma44Scale44to44perform44a44neurologic44asses
sment.44A44comatose44client44winces44and44pulls44away44from44a44painful44stimulus.44W
hich44action44should44the44nurse44take44next?
A.44Document44that44the44client44responds44to44painful44stimulus.
B.44Observe44the44client's44response44to44verbal44stimulation.
C.44Place44the44client44on44seizure44precautions44for442444hours.
D.44Report44decorticate44posturing44to44the44health44care44provider44-44answer--.A
Rationale:44The44client44has44demonstrated44a44purposeful44response44to44pain,44which4
4should44be44documented44as44such.44Response44to44painful44stimulus44is44assessed44a
fter44response44to44verbal44stimulus,44not44before.44There44is44no44indication44for44placin
g44the44client44on44seizure44precautions.44Reporting44decorticate44posturing44to44the44he
alth44care44provider44is44nonpurposeful44movement.
The44nurse44plans44to44administer44diazepam,44444mg44IV44push,44to44a44client44with44se
vere44anxiety.44How44many44milliliters44should44the44nurse44administer?
44(Round44to44the44nearest44tenth.)
A.440.244mL
B.440.844mL
C.441.2544mL
D.442.044mL44-44answer--B
Rationale:44(144mL44×44444mg)/544mg44=440.844mL
QUESTIONS
When44turning44an44immobile44bedridden44client44without44assistance,44which44action44b
y44the44nurse44best44ensures44client44safety?
A.44Securely44grasp44the44client's44arm44and44leg.
B.44Put44bed44rails44up44on44the44side44of44bed44opposite44from44the44nurse.
C.44Correctly44position44and44use44a44turn44sheet.
D.44Lower44the44head44of44the44client's44bed44slowly.44-44answer--B
Rationale:44Because44the44nurse44can44only44stand44on44one44side44of44the44bed,44bed4
4rails44should44be44up44on44the44opposite44side44to44ensure44that44the44client44does44not
44fall44out44of44bed.44Option44A44can44cause44client44injury44to44the44skin44or44joint.44Opti
ons44C44and44D44are44useful44techniques44while44turning44a44client44but44have44less44pri
ority44in44terms44of44safety44than44use44of44the44bed44rails.
The44nurse44identifies44a44potential44for44infection44in44a44client44with44partial-
thickness44(second-degree)44and44full-thickness44(third-
degree)44burns.44What44intervention44has44the44highest44priority44in44decreasing44the44cl
ient's44risk44of44infection?
A.44Administration44of44plasma44expanders
B.44Use44of44careful44handwashing44technique
C.44Application44of44a44topical44antibacterial44cream
D.44Limiting44visitors44to44the44client44with44burns44-44answer--B
Rationale:44Careful44handwashing44technique44is44the44single44most44effective44interven
tion44for44the44prevention44of44contamination44to44all44clients.44Option44A44reverses44the4
4hypovolemia44that44initially44accompanies44burn44trauma44but44is44not44related44to44dec
reasing44the44proliferation44of44infective44organisms.44Options44C44and44D44are44recom
mended44by44various44burn44centers44as44possible44ways44to44reduce44the44chance44of4
4infection.44Option44B44is44a44proven44technique44to44prevent44infection.
The44nurse44is44aware44that44malnutrition44is44a44common44problem44among44clients44s
erved44by44a44community44health44clinic44for44the44homeless.44Which44laboratory44value
44is44the44most44reliable44indicator44of44chronic44protein44malnutrition?
A.44Low44serum44albumin44level
B.44Low44serum44transferrin44level
,C.44High44hemoglobin44level
D.44High44cholesterol44level44-44answer--A
Rationale:44Long-
term44protein44deficiency44is44required44to44cause44significantly44lowered44serum44album
in44levels.44Albumin44is44made44by44the44liver44only44when44adequate44amounts44of44am
ino44acids44(from44protein44breakdown)44are44available.44Albumin44has44a44long44half-
life,44so44acute44protein44loss44does44not44significantly44alter44serum44levels.44Option44B
44is44a44serum44protein44with44a44half-
life44of44only44844to441044days,44so44it44will44drop44with44an44acute44protein44deficiency.44
Options44C44and44D44are44not44clinical44measures44of44protein44malnutrition.
In44completing44a44client's44preoperative44routine,44the44nurse44finds44that44the44operativ
e44permit44is44not44signed.44The44client44begins44to44ask44more44questions44about44the44
surgical44procedure.44Which44action44should44the44nurse44take44next?
A.44Witness44the44client's44signature44to44the44permit.
B.44Answer44the44client's44questions44about44the44surgery.
C.44Inform44the44surgeon44that44the44operative44permit44is44not44signed44and44the44client
44has44questions44about44the44surgery.
D.44Reassure44the44client44that44the44surgeon44will44answer44any44questions44before44th
e44anesthesia44is44administered.44-44answer--C
Rationale:44The44surgeon44should44be44informed44immediately44that44the44permit44is44no
t44signed.44It44is44the44surgeon's44responsibility44to44explain44the44procedure44to44the44cli
ent44and44obtain44the44client's44signature44on44the44permit.44Although44the44nurse44can44
witness44an44operative44permit,44the44procedure44must44first44be44explained44by44the44h
ealth44care44provider44or44surgeon,44including44answering44the44client's44questions.44Th
e44client's44questions44should44be44addressed44before44the44permit44is44signed.
The44nurse44is44assessing44several44clients44prior44to44surgery.44Which44factor44in44a44cl
ient's44history44poses44the44greatest44threat44for44complications44to44occur44during44surg
ery?
A.44Taking44birth44control44pills44for44the44past44244years
B.44Taking44anticoagulants44for44the44past44year
C.44Recently44completing44antibiotic44therapy
D.44Having44taken44laxatives44PRN44for44the44last44644months44-44answer--B
Rationale:
Anticoagulants44increase44the44risk44for44bleeding44during44surgery,44which44can44pose4
4a44threat44for44the44development44of44surgical44complications.44The44health44care44prov
ider44should44be44informed44that44the44client44is44taking44these44drugs.44Although44client
s44who44take44birth44control44pills44may44be44more44susceptible44to44the44development44
of44thrombi,44such44problems44usually44occur44postoperatively.44A44client44with44option44
C44or44D44is44at44less44of44a44surgical44risk44than44with44option44B.
When44assisting44a44client44from44the44bed44to44a44chair,44which44procedure44is44best44f
or44the44nurse44to44follow?
A.44Place44the44chair44parallel44to44the44bed,44with44its44back44toward44the44head44of44th
e44bed44and44assist44the44client44in44moving44to44the44chair.
,B.44With44the44nurse's44feet44spread44apart44and44knees44aligned44with44the44client's44kn
ees,44stand44and44pivot44the44client44into44the44chair.
C.44Assist44the44client44to44a44standing44position44by44gently44lifting44upward,44undernea
th44the44axillae.
D.44Stand44beside44the44client,44place44the44client's44arms44around44the44nurse's44neck,4
4and44gently44move44the44client44to44the44chair.44-44answer--B
Rationale:44Option44B44describes44the44correct44positioning44of44the44nurse44and44afford
s44the44nurse44a44wide44base44of44support44while44stabilizing44the44client's44knees44whe
n44assisting44to44a44standing44position.44The44chair44should44be44placed44at44a4445-
degree44angle44to44the44bed,44with44the44back44of44the44chair44toward44the44head44of44th
e44bed.44Clients44should44never44be44lifted44under44the44axillae;44this44could44damage44
nerves44and44strain44the44nurse's44back.44The44client44should44be44instructed44to44use44t
he44arms44of44the44chair44and44should44never44place44his44or44her44arms44around44the44
nurse's44neck;44this44places44undue44stress44on44the44nurse's44neck44and44back44and44i
ncreases44the44risk44for44a44fall.
Which44step(s)44should44the44nurse44take44when44administering44ear44drops44to44an44ad
ult44client?44(Select44all44that44apply.)
A.44Place44the44client44in44a44side-lying44position.
B.44Pull44the44auricle44upward44and44outward.
C.44Hold44the44dropper44644cm44above44the44ear44canal.
D.44Place44a44cotton44ball44into44the44inner44canal.
E.44Pull44the44auricle44down44and44back.44-44answer--A,44B
Rationale:44The44correct44answers44(A44and44B)44are44the44appropriate44administration44
of44ear44drops.44The44dropper44should44be44held44144cm44(½44inch)44above44the44ear44c
anal44(C).44A44cotton44ball44should44be44placed44in44the44outermost44canal44(D).44The44a
uricle44is44pulled44down44and44back44for44a44child44younger44than44344years44of44age,44b
ut44not44an44adult44(E).
The44nurse44is44instructing44a44client44in44the44proper44use44of44a44metered-
dose44inhaler.44Which44instruction44should44the44nurse44provide44the44client44to44ensure
44the44optimal44benefits44from44the44drug?
A.44"Fill44your44lungs44with44air44through44your44mouth44and44then44compress44the44inha
ler."
B.44"Compress44the44inhaler44while44slowly44breathing44in44through44your44mouth."
C.44"Compress44the44inhaler44while44inhaling44quickly44through44your44nose."
D.44"Exhale44completely44after44compressing44the44inhaler44and44then44inhale."44-
44answer--B
Rationale:44The44medication44should44be44inhaled44through44the44mouth44simultaneousl
y44with44compression44of44the44inhaler.44This44will44facilitate44the44desired44destination44
of44the44aerosol44medication44deep44in44the44lungs44for44an44optimal44bronchodilation44e
ffect.44Options44A,44C,44and44D44do44not44allow44for44deep44lung44penetration.
A4420-year-
old44female44client44with44a44noticeable44body44odor44has44refused44to44shower44for44the
, 44last44344days.44She44states,44"I44have44been44told44that44it44is44harmful44to44bathe44duri
ng44my44period."44Which44action44should44the44nurse44take44first?
A.44Accept44and44document44the44client's44wish44to44refrain44from44bathing.
B.44Offer44to44give44the44client44a44bed44bath,44avoiding44the44perineal44area.
C.44Obtain44written44brochures44about44menstruation44to44give44to44the44client.
D.44Teach44the44importance44of44personal44hygiene44during44menstruation44with44the44cl
ient.44-44answer--D
Rationale:44Because44a44shower44is44most44beneficial44for44the44client44in44terms44of44hy
giene,44the44client44should44receive44teaching44first,44respecting44any44personal44beliefs
44such44as44cultural44or44spiritual44values.44After44client44teaching,44the44client44may44stil
l44choose44option44A44or44B.44Brochures44reinforce44the44teaching.
While44reviewing44the44side44effects44of44a44newly44prescribed44medication,44a4472-
year-
old44client44notes44that44one44of44the44side44effects44is44a44reduction44in44sexual44drive.4
4Which44is44the44best44response44by44the44nurse?
A.44"How44will44this44affect44your44present44sexual44activity?"
B.44"How44active44is44your44current44sex44life?"
C.44"How44has44your44sex44life44changed44as44you44have44become44older?"
D.44"Tell44me44about44your44sexual44needs44as44an44older44adult."44-44answer--A
Rationale:44Option44A44offers44an44open-
ended44question44most44relevant44to44the44client's44statement.44Option44B44does44not44o
ffer44the44client44the44opportunity44to44express44concerns.44Options44C44and44D44are44ev
en44less44relevant44to44the44client's44statement.
The44nurse44is44using44the44Glasgow44Coma44Scale44to44perform44a44neurologic44asses
sment.44A44comatose44client44winces44and44pulls44away44from44a44painful44stimulus.44W
hich44action44should44the44nurse44take44next?
A.44Document44that44the44client44responds44to44painful44stimulus.
B.44Observe44the44client's44response44to44verbal44stimulation.
C.44Place44the44client44on44seizure44precautions44for442444hours.
D.44Report44decorticate44posturing44to44the44health44care44provider44-44answer--.A
Rationale:44The44client44has44demonstrated44a44purposeful44response44to44pain,44which4
4should44be44documented44as44such.44Response44to44painful44stimulus44is44assessed44a
fter44response44to44verbal44stimulus,44not44before.44There44is44no44indication44for44placin
g44the44client44on44seizure44precautions.44Reporting44decorticate44posturing44to44the44he
alth44care44provider44is44nonpurposeful44movement.
The44nurse44plans44to44administer44diazepam,44444mg44IV44push,44to44a44client44with44se
vere44anxiety.44How44many44milliliters44should44the44nurse44administer?
44(Round44to44the44nearest44tenth.)
A.440.244mL
B.440.844mL
C.441.2544mL
D.442.044mL44-44answer--B
Rationale:44(144mL44×44444mg)/544mg44=440.844mL
