HESI FUNDAMENTALS EXAM 2026/2027 | 100% Correct
Answers with Complete Solutions | NCLEX-RN Aligned |
Foundational Nursing | Clinical Judgment | Pass Guaranteed
- A+ Graded
Domain 1: Safe & Effective Care Environment (25 Questions)
Q1: A 78-year-old client with dementia is admitted to the medical-surgical unit after a
fall at home. The client is agitated, attempting to remove their IV line, and trying to get
out of bed unassisted. The nurse observes that the client is unsteady on their feet and
has a history of previous falls. Which nursing intervention is the PRIORITY to ensure
client safety?
A. Apply wrist restraints to prevent IV line removal and keep the side rails up at all times
B. Place the client in a room near the nurses' station, implement hourly rounding, use a
bed alarm, and ensure non-skid footwear [CORRECT]
C. Administer a sedative medication to keep the client calm and in bed
D. Assign a family member to stay with the client 24 hours a day
Correct Answer: B
,Rationale: The priority is fall prevention using the least restrictive interventions first.
Placing the client near the nurses' station allows for closer observation; hourly rounding
addresses toileting needs (a common fall cause); bed alarms alert staff when the client
attempts to get up; and non-skid footwear prevents slipping. This follows the hierarchy
of fall prevention: environmental modifications and surveillance before physical or
chemical restraints. Option A is incorrect because restraints are a last resort per CMS
guidelines and require a physician order, assessment every 2 hours, and specific
documentation; they also increase injury risk if the client struggles. Option C is incorrect
because chemical restraints (sedation) are inappropriate without medical indication and
increase fall risk through orthostatic hypotension and confusion. Option D is
inappropriate because family presence is not a nursing intervention and cannot be
required or guaranteed.
Q2: A nurse is caring for a client with confirmed Clostridioides difficile (C. diff) infection.
Which personal protective equipment (PPE) and infection control measures are
REQUIRED when entering the client's room?
A. Standard precautions only (gloves and hand hygiene with alcohol-based sanitizer)
B. Contact precautions with gown and gloves, and hand washing with soap and water
[CORRECT]
C. Droplet precautions with surgical mask and eye protection
D. Airborne precautions with N95 respirator and negative pressure room
,Correct Answer: B
Rationale: C. diff requires Contact precautions (gown and gloves for room entry)
because it spreads via contact with contaminated surfaces or fecal-oral route. Crucially,
hand hygiene MUST be with soap and water because C. diff spores are resistant to
alcohol-based hand sanitizers. The physical friction of hand washing removes spores.
Option A is incorrect because alcohol sanitizer does not kill C. diff spores and standard
precautions are insufficient. Option C is incorrect because C. diff is not spread by
droplets (requires coughing/sneezing). Option D is incorrect because airborne
transmission requires pathogens that remain infectious over long distances (TB,
measles, varicella).
Q3: A client with tuberculosis (TB) is admitted to the hospital. Which room assignment
and PPE are appropriate for healthcare workers?
A. Standard precautions in a semi-private room with another client who has pneumonia
B. Droplet precautions in a private room with the door closed
C. Airborne precautions in a negative pressure room with N95 respirator [CORRECT]
D. Contact precautions with gown and gloves in any available private room
Correct Answer: C
, Rationale: TB is transmitted via airborne droplet nuclei (particles <5 microns that remain
suspended in air), requiring Airborne precautions: negative pressure room (air
exhausted outside or HEPA filtered), N95 respirator (or PAPR) for all room entrants, and
door kept closed. This prevents airborne transmission to other areas. Option A is
incorrect because TB is not standard precautions and requires isolation. Option B
confuses Droplet (particles >5 microns, 3-6 feet transmission) with Airborne. Option D
confuses contact transmission (direct/indirect touch) with airborne.
Q4: A nurse witnesses a medication error where a client received 10 units of regular
insulin instead of the prescribed 10 units of long-acting insulin. The client's blood
glucose is currently 94 mg/dL. What is the nurse's FIRST action?
A. Immediately notify the physician and complete an incident report
B. Check the client's blood glucose, provide a carbohydrate snack, and monitor closely
for hypoglycemia [CORRECT]
C. Wait to see if symptoms of hypoglycemia develop before taking action
D. Administer 10 units of long-acting insulin to correct the error
Correct Answer: B
Rationale: The immediate priority is client safety. Regular insulin is rapid-acting and will
cause hypoglycemia. With blood glucose at 94 mg/dL (low-normal), the nurse must
prevent hypoglycemia by providing carbohydrates and monitoring closely. This follows
Answers with Complete Solutions | NCLEX-RN Aligned |
Foundational Nursing | Clinical Judgment | Pass Guaranteed
- A+ Graded
Domain 1: Safe & Effective Care Environment (25 Questions)
Q1: A 78-year-old client with dementia is admitted to the medical-surgical unit after a
fall at home. The client is agitated, attempting to remove their IV line, and trying to get
out of bed unassisted. The nurse observes that the client is unsteady on their feet and
has a history of previous falls. Which nursing intervention is the PRIORITY to ensure
client safety?
A. Apply wrist restraints to prevent IV line removal and keep the side rails up at all times
B. Place the client in a room near the nurses' station, implement hourly rounding, use a
bed alarm, and ensure non-skid footwear [CORRECT]
C. Administer a sedative medication to keep the client calm and in bed
D. Assign a family member to stay with the client 24 hours a day
Correct Answer: B
,Rationale: The priority is fall prevention using the least restrictive interventions first.
Placing the client near the nurses' station allows for closer observation; hourly rounding
addresses toileting needs (a common fall cause); bed alarms alert staff when the client
attempts to get up; and non-skid footwear prevents slipping. This follows the hierarchy
of fall prevention: environmental modifications and surveillance before physical or
chemical restraints. Option A is incorrect because restraints are a last resort per CMS
guidelines and require a physician order, assessment every 2 hours, and specific
documentation; they also increase injury risk if the client struggles. Option C is incorrect
because chemical restraints (sedation) are inappropriate without medical indication and
increase fall risk through orthostatic hypotension and confusion. Option D is
inappropriate because family presence is not a nursing intervention and cannot be
required or guaranteed.
Q2: A nurse is caring for a client with confirmed Clostridioides difficile (C. diff) infection.
Which personal protective equipment (PPE) and infection control measures are
REQUIRED when entering the client's room?
A. Standard precautions only (gloves and hand hygiene with alcohol-based sanitizer)
B. Contact precautions with gown and gloves, and hand washing with soap and water
[CORRECT]
C. Droplet precautions with surgical mask and eye protection
D. Airborne precautions with N95 respirator and negative pressure room
,Correct Answer: B
Rationale: C. diff requires Contact precautions (gown and gloves for room entry)
because it spreads via contact with contaminated surfaces or fecal-oral route. Crucially,
hand hygiene MUST be with soap and water because C. diff spores are resistant to
alcohol-based hand sanitizers. The physical friction of hand washing removes spores.
Option A is incorrect because alcohol sanitizer does not kill C. diff spores and standard
precautions are insufficient. Option C is incorrect because C. diff is not spread by
droplets (requires coughing/sneezing). Option D is incorrect because airborne
transmission requires pathogens that remain infectious over long distances (TB,
measles, varicella).
Q3: A client with tuberculosis (TB) is admitted to the hospital. Which room assignment
and PPE are appropriate for healthcare workers?
A. Standard precautions in a semi-private room with another client who has pneumonia
B. Droplet precautions in a private room with the door closed
C. Airborne precautions in a negative pressure room with N95 respirator [CORRECT]
D. Contact precautions with gown and gloves in any available private room
Correct Answer: C
, Rationale: TB is transmitted via airborne droplet nuclei (particles <5 microns that remain
suspended in air), requiring Airborne precautions: negative pressure room (air
exhausted outside or HEPA filtered), N95 respirator (or PAPR) for all room entrants, and
door kept closed. This prevents airborne transmission to other areas. Option A is
incorrect because TB is not standard precautions and requires isolation. Option B
confuses Droplet (particles >5 microns, 3-6 feet transmission) with Airborne. Option D
confuses contact transmission (direct/indirect touch) with airborne.
Q4: A nurse witnesses a medication error where a client received 10 units of regular
insulin instead of the prescribed 10 units of long-acting insulin. The client's blood
glucose is currently 94 mg/dL. What is the nurse's FIRST action?
A. Immediately notify the physician and complete an incident report
B. Check the client's blood glucose, provide a carbohydrate snack, and monitor closely
for hypoglycemia [CORRECT]
C. Wait to see if symptoms of hypoglycemia develop before taking action
D. Administer 10 units of long-acting insulin to correct the error
Correct Answer: B
Rationale: The immediate priority is client safety. Regular insulin is rapid-acting and will
cause hypoglycemia. With blood glucose at 94 mg/dL (low-normal), the nurse must
prevent hypoglycemia by providing carbohydrates and monitoring closely. This follows
