HESI FUNDAMENTALS V2 FINAL PAPER
2026 COMPLETE SOLUTIONS AND
CORRECT ANSWERS GRADED A+
⩥ The nurse is counting a client's respiratory rate. During a 30-second
interval, the nurse counts six respirations and the client coughs three
times. In repeating the count for a second 30-second interval, the nurse
counts eight respirations. Which respiratory rate should the nurse
document?
A. 14
B. 16
C. 17
D. 28. Answer: B
Rationale: The most accurate respiratory rate is the second count
obtained by the nurse, which was not interrupted by coughing. Because
it was counted for 30 seconds, the rate should be doubled. Options A, C,
and D are inaccurate recordings.
⩥ The nurse is teaching an obese client, newly diagnosed with
arteriosclerosis, about reducing the risk of a heart attack or stroke.
Which health promotion brochure is most important for the nurse to
provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
,C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You" Answer: C
Rationale: A health promotion brochure about decreasing cholesterol is
most important to provide this client, because the most significant risk
factor contributing to development of arteriosclerosis is excess dietary
fat, particularly saturated fat and cholesterol. Option A does not address
the underlying causes of arteriosclerosis. Options B and D are also
important factors for reversing arteriosclerosis but are not as important
as lowering cholesterol.
⩥ The nurse finds a client crying behind a locked bathroom door. The
client will not open the door. Which action should the nurse implement
first?
A. Instruct an unlicensed assistive personnel (UAP) to stay and keep
talking to the client.
B. Sit quietly in the client's room until the client leaves the bathroom.
C. Allow the client to cry alone and leave the client in the bathroom.
D. Talk to the client and attempt to find out why the client is crying.
Answer: D
Rationale: The nurse's first concern should be for the client's safety, so
an immediate assessment of the client's situation is needed. Option A is
incorrect; the nurse should implement the intervention. The nurse may
offer to stay nearby after first assessing the situation more fully.
Although option C may be correct, the nurse should determine if the
client's safety is compromised and offer assistance, even if it is refused.
,⩥ A client in a long-term care facility reports to the nurse that he has not
had a bowel movement in 2 days. Which intervention should the nurse
implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at
mealtimes.
B. Notify the health care provider and request a prescription for a large-
volume enema.
C. Assess the client's medical record to determine the client's normal
bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce
glasses per day. Answer: C
Rationale: This client may not routinely have a daily bowel movement,
so the nurse should first assess this client's normal bowel habits before
attempting any intervention. Option A, B, or D may then be
implemented, if warranted.
⩥ A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which instruction is
most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. Answer: B
Rationale: The most important teaching is to change positions frequently
because pressure is the most significant factor related to the
, development of pressure ulcers. Increased vitamin and fluid intake may
also be beneficial and promote healing and reduce further risk. Option D
is an intervention of last resort because this will be very expensive for
the client.
⩥ Urinary catheterization is prescribed for a postoperative female client
who has been unable to void for 8 hours. The nurse inserts the catheter,
but no urine is seen in the tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction. Answer: C
Rationale: It is likely that the first catheter is in the vagina, rather than
the bladder. Leaving the first catheter in place will help locate the
meatus when attempting the second catheterization. The client should
have at least 240 mL of urine after 8 hours. Option A does not resolve
the problem. Option B will not change the location of the catheter unless
it is completely removed, in which case a new catheter must be used.
There is no evidence of a urinary tract obstruction if the catheter could
be easily inserted.
⩥ The mental health nurse plans to discuss a client's depression with the
health care provider in the emergency department. There are two clients
sitting across from the emergency department desk. Which nursing
action is best?
A. Only refer to the client by gender.
2026 COMPLETE SOLUTIONS AND
CORRECT ANSWERS GRADED A+
⩥ The nurse is counting a client's respiratory rate. During a 30-second
interval, the nurse counts six respirations and the client coughs three
times. In repeating the count for a second 30-second interval, the nurse
counts eight respirations. Which respiratory rate should the nurse
document?
A. 14
B. 16
C. 17
D. 28. Answer: B
Rationale: The most accurate respiratory rate is the second count
obtained by the nurse, which was not interrupted by coughing. Because
it was counted for 30 seconds, the rate should be doubled. Options A, C,
and D are inaccurate recordings.
⩥ The nurse is teaching an obese client, newly diagnosed with
arteriosclerosis, about reducing the risk of a heart attack or stroke.
Which health promotion brochure is most important for the nurse to
provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
,C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You" Answer: C
Rationale: A health promotion brochure about decreasing cholesterol is
most important to provide this client, because the most significant risk
factor contributing to development of arteriosclerosis is excess dietary
fat, particularly saturated fat and cholesterol. Option A does not address
the underlying causes of arteriosclerosis. Options B and D are also
important factors for reversing arteriosclerosis but are not as important
as lowering cholesterol.
⩥ The nurse finds a client crying behind a locked bathroom door. The
client will not open the door. Which action should the nurse implement
first?
A. Instruct an unlicensed assistive personnel (UAP) to stay and keep
talking to the client.
B. Sit quietly in the client's room until the client leaves the bathroom.
C. Allow the client to cry alone and leave the client in the bathroom.
D. Talk to the client and attempt to find out why the client is crying.
Answer: D
Rationale: The nurse's first concern should be for the client's safety, so
an immediate assessment of the client's situation is needed. Option A is
incorrect; the nurse should implement the intervention. The nurse may
offer to stay nearby after first assessing the situation more fully.
Although option C may be correct, the nurse should determine if the
client's safety is compromised and offer assistance, even if it is refused.
,⩥ A client in a long-term care facility reports to the nurse that he has not
had a bowel movement in 2 days. Which intervention should the nurse
implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at
mealtimes.
B. Notify the health care provider and request a prescription for a large-
volume enema.
C. Assess the client's medical record to determine the client's normal
bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce
glasses per day. Answer: C
Rationale: This client may not routinely have a daily bowel movement,
so the nurse should first assess this client's normal bowel habits before
attempting any intervention. Option A, B, or D may then be
implemented, if warranted.
⩥ A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which instruction is
most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. Answer: B
Rationale: The most important teaching is to change positions frequently
because pressure is the most significant factor related to the
, development of pressure ulcers. Increased vitamin and fluid intake may
also be beneficial and promote healing and reduce further risk. Option D
is an intervention of last resort because this will be very expensive for
the client.
⩥ Urinary catheterization is prescribed for a postoperative female client
who has been unable to void for 8 hours. The nurse inserts the catheter,
but no urine is seen in the tubing. Which action will the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction. Answer: C
Rationale: It is likely that the first catheter is in the vagina, rather than
the bladder. Leaving the first catheter in place will help locate the
meatus when attempting the second catheterization. The client should
have at least 240 mL of urine after 8 hours. Option A does not resolve
the problem. Option B will not change the location of the catheter unless
it is completely removed, in which case a new catheter must be used.
There is no evidence of a urinary tract obstruction if the catheter could
be easily inserted.
⩥ The mental health nurse plans to discuss a client's depression with the
health care provider in the emergency department. There are two clients
sitting across from the emergency department desk. Which nursing
action is best?
A. Only refer to the client by gender.
