HESI Fundamentals Exam Practice
Questions
A female nurse who sometimes tries to save time by putting medications in her uniform pocket
to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet
in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?
A.) Accused of diversion.
B.) Reported for stealing.
C.) Reported for a HIPAA violation.
D.) Accused of unprofessional conduct. - ✔✔A
Rationale: Even if this is only one incident, the nurse may be suspected of taking medications
on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics
for her own use, which should be reported to the peer review committee and to the State
Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible
outcome.
A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the
nurse to implement when caring for this client?
A.) Use distraction techniques during times of spiritual stress and crisis.
B.) Reassure the client that his faith will be regained with time and support.
C.) Consult with the staff chaplain and ask that the chaplain visit with the client.
D.) Use reflective listening techniques when the client expresses spiritual doubts. - ✔✔D
Rationale: The most beneficial nursing intervention is to use nonjudgmental reflective listening
techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not
therapeutic. The client should be consulted before implementing (C).
,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. - ✔✔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.
The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of
175 ml/hour. Which infusion device should the nurse use?
A.) Portable syringe pump.
B.) Cassette infusion pump.
C.) Volumetric controller.
D.) Nonvolumetric controller. - ✔✔B
Rationale: A cassette pump (B) should be used to accurately deliver large volumes of fluid over
longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate
for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid
volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to
administer fluid volume and are inherently inaccurate because of variation in drop size.
How should the nurse handle linens that are soiled with incontinent feces?
,A.) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
B.) Place an isolation hamper in the client's room and discard the linens in it.
C.) Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
D.) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room. - ✔✔C
Rationale: The nurse should be careful to keep the soiled linens from contaminating the fresh
linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not
indicated.
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. - ✔✔A, B, C, E
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.
Which technique is most important for the nurse to implement when performing a physical
assessment?
A.) A head-to-toe approach.
B.) The medical systems model.
, C.) A consistent, systematic approach.
D.) An approach related to a nursing model. - ✔✔C
Rationale: 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
discretion of the examiner, but a consistent sequence by the examiner provides a reliable
method to ensure thorough review of the clients' history, complaints, or body systems.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would
indicate to the nurse that this client understands the dietary restrictions?
A.) Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B.) New England clam chowder, no-salt crackers, fresh fruit salad.
C.) Skim milk, turkey salad, roll, and vanilla ice cream.
D.) Macaroni and cheese, diet Coke, a slice of cherry pie. - ✔✔C
Rationale: Skim milk, turkey, bread, and ice cream, while containing some sodium, are
considered low-sodium foods. Bacon, canned soups, especially those with seafood, hard
cheeses, macaroni, and most diet drinks are very high in sodium.
Which step in the nursing process would involve promoting a safe environment for the client?
A.) Planning
B.) Diagnosis
C.) Assessment
D.) Implementation - ✔✔D
Rationale: The nurse promotes a safe environment during the implementation stage of the
nursing process. During the planning stage, the nurse develops an individualized care plan for
Questions
A female nurse who sometimes tries to save time by putting medications in her uniform pocket
to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet
in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?
A.) Accused of diversion.
B.) Reported for stealing.
C.) Reported for a HIPAA violation.
D.) Accused of unprofessional conduct. - ✔✔A
Rationale: Even if this is only one incident, the nurse may be suspected of taking medications
on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics
for her own use, which should be reported to the peer review committee and to the State
Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible
outcome.
A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the
nurse to implement when caring for this client?
A.) Use distraction techniques during times of spiritual stress and crisis.
B.) Reassure the client that his faith will be regained with time and support.
C.) Consult with the staff chaplain and ask that the chaplain visit with the client.
D.) Use reflective listening techniques when the client expresses spiritual doubts. - ✔✔D
Rationale: The most beneficial nursing intervention is to use nonjudgmental reflective listening
techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not
therapeutic. The client should be consulted before implementing (C).
,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. - ✔✔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.
The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of
175 ml/hour. Which infusion device should the nurse use?
A.) Portable syringe pump.
B.) Cassette infusion pump.
C.) Volumetric controller.
D.) Nonvolumetric controller. - ✔✔B
Rationale: A cassette pump (B) should be used to accurately deliver large volumes of fluid over
longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate
for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid
volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to
administer fluid volume and are inherently inaccurate because of variation in drop size.
How should the nurse handle linens that are soiled with incontinent feces?
,A.) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper.
B.) Place an isolation hamper in the client's room and discard the linens in it.
C.) Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.
D.) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room. - ✔✔C
Rationale: The nurse should be careful to keep the soiled linens from contaminating the fresh
linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not
indicated.
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. - ✔✔A, B, C, E
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.
Which technique is most important for the nurse to implement when performing a physical
assessment?
A.) A head-to-toe approach.
B.) The medical systems model.
, C.) A consistent, systematic approach.
D.) An approach related to a nursing model. - ✔✔C
Rationale: 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
discretion of the examiner, but a consistent sequence by the examiner provides a reliable
method to ensure thorough review of the clients' history, complaints, or body systems.
The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would
indicate to the nurse that this client understands the dietary restrictions?
A.) Tossed salad, low-sodium dressing, bacon and tomato sandwich.
B.) New England clam chowder, no-salt crackers, fresh fruit salad.
C.) Skim milk, turkey salad, roll, and vanilla ice cream.
D.) Macaroni and cheese, diet Coke, a slice of cherry pie. - ✔✔C
Rationale: Skim milk, turkey, bread, and ice cream, while containing some sodium, are
considered low-sodium foods. Bacon, canned soups, especially those with seafood, hard
cheeses, macaroni, and most diet drinks are very high in sodium.
Which step in the nursing process would involve promoting a safe environment for the client?
A.) Planning
B.) Diagnosis
C.) Assessment
D.) Implementation - ✔✔D
Rationale: The nurse promotes a safe environment during the implementation stage of the
nursing process. During the planning stage, the nurse develops an individualized care plan for
