HESI FUNDAMENTALS PRACTICE TEST FINAL 2 NCLEX
2026/2027 | Updated Edition with 100% Correct Answers |
Nursing Fundamentals Exam Prep | Pass Guaranteed - A+
Graded
Client Needs: Safe and Effective Care Environment (20 Questions)
Q1: The nurse receives shift report on four clients. Which client should the nurse assess
first?
A. A 45-year-old client 2 hours post-appendectomy with pain rated 3/10 and stable vital
signs
B. A 62-year-old client with heart failure who received 40mg IV furosemide 1 hour ago
and reports feeling "short of breath" [CORRECT]
C. A 28-year-old client admitted for observation after a mild concussion, alert and
oriented ×4
D. A 55-year-old client with diabetes mellitus requesting assistance with insulin injection
before breakfast
Correct Answer: B
Rationale: Using the ABCs (Airway, Breathing, Circulation) priority framework, Client B
presents with a potential breathing problem—"short of breath" after diuretic
administration suggests possible flash pulmonary edema or worsening heart failure,
which is life-threatening. The nurse must assess immediately to evaluate oxygenation
status and respiratory distress. Client A has controlled post-op pain (expected). Client C
is stable with resolved neuro status. Client D's request is important but not
urgent—insulin timing is flexible within a window. The distractor D represents a common
trap: diabetes management seems urgent, but ABCs always take precedence over
scheduled medications.
,Q2: A client with a central venous catheter (CVC) develops sudden dyspnea, chest pain,
and tachycardia during infusion of total parenteral nutrition (TPN). What is the nurse's
first action?
A. Stop the TPN infusion immediately [CORRECT]
B. Obtain a stat chest x-ray
C. Administer supplemental oxygen at 4L nasal cannula
D. Elevate the head of the bed to 90 degrees
Correct Answer: A
Rationale: These symptoms indicate potential air embolism or catheter-related
complication—immediately stopping the infusion prevents further air/fluid entry into the
circulation. While oxygen (C) and positioning (D) support respiratory status, stopping
the source is priority. Chest x-ray (B) is diagnostic but not immediate. The clinical
judgment pathway: recognize life-threatening complication → stop causative agent →
then implement supportive measures. Distractor C is a common second-priority
trap—oxygen is supportive but doesn't address the cause.
Q3: Which task is appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Assessing a postoperative client's incision for signs of infection
B. Obtaining a blood glucose reading on a stable diabetic client before mealtime
[CORRECT]
C. Teaching a newly diagnosed asthmatic client how to use a peak flow meter
D. Administering an oral antibiotic to a client with pneumonia
Correct Answer: B
Rationale: Delegation follows the "right task, right circumstance, right person, right
direction/communication, right supervision" framework. Blood glucose monitoring on a
,stable client is a routine, repetitive task with predictable outcomes that UAPs are trained
to perform. Assessment (A), teaching (C), and medication administration (D) require
nursing judgment, education, or licensure and cannot be delegated. Distractor A is a
frequent error—UAPs can report observations but cannot perform clinical assessments
requiring interpretation.
Q4: The nurse enters a client's room and finds the client unconscious on the floor
beside the bed. The bed alarm was not activated. What is the priority nursing action?
A. Call for help and activate the rapid response team
B. Assess the client's airway, breathing, and circulation [CORRECT]
C. Document the incident in the electronic health record
D. Return the client to bed using a lift device
Correct Answer: B
Rationale: The ABCs of emergency assessment apply—before moving the client or
calling codes, the nurse must determine if the client is breathing and has a pulse. This
30-second assessment determines whether CPR or emergency protocols are needed.
Calling for help (A) is appropriate but assessment comes first (you cannot effectively
communicate the emergency level without knowing the client's status). Documentation
(C) and repositioning (D) are never priorities over life-safety assessment. Distractor A
represents the "call for help first" trap—while important, the nurse must assess before
acting.
Q5: A client is prescribed contact isolation for methicillin-resistant Staphylococcus
aureus (MRSA) wound infection. Which action by the nurse demonstrates appropriate
infection control?
A. Wearing an N95 respirator when entering the room
, B. Performing hand hygiene with alcohol-based sanitizer before donning gloves
[CORRECT]
C. Placing the client in a negative pressure room
D. Wearing a gown only when changing the wound dressing
Correct Answer: B
Rationale: Contact isolation requires gloves and gown for room entry, with hand hygiene
before donning and after doffing PPE. Alcohol-based sanitizer is appropriate for hand
hygiene unless hands are visibly soiled. N95 respirators (A) are for airborne precautions.
Negative pressure (C) is for airborne isolation (TB, measles, varicella). Gowns are
required for all room entry (D), not just dressing changes. Distractor D represents a
common shortcut error—standard precautions require consistent PPE use, not
task-selective application.
Q6: The nurse is preparing to administer medications to four clients. Which situation
requires immediate intervention by the nurse?
A. A client with penicillin allergy prescribed azithromycin for respiratory infection
B. A client with a potassium level of 3.2 mEq/L prescribed furosemide 20mg PO
[CORRECT]
C. A client with blood pressure 138/88 prescribed hydrochlorothiazide 25mg PO
D. A client with heart rate 58 bpm prescribed metoprolol 50mg PO
Correct Answer: B
Rationale: Potassium 3.2 mEq/L indicates hypokalemia (normal 3.5-5.0). Furosemide is
a potassium-wasting diuretic that will further deplete potassium, risking dangerous
arrhythmias. The nurse must hold the medication and contact the provider.
Azithromycin (A) is appropriate for penicillin-allergic clients (different drug class). BP
138/88 (C) is mildly elevated—hydrochlorothiazide is appropriate. HR 58 (D) is
low-normal; while caution is warranted with beta-blockers, it's not an absolute
2026/2027 | Updated Edition with 100% Correct Answers |
Nursing Fundamentals Exam Prep | Pass Guaranteed - A+
Graded
Client Needs: Safe and Effective Care Environment (20 Questions)
Q1: The nurse receives shift report on four clients. Which client should the nurse assess
first?
A. A 45-year-old client 2 hours post-appendectomy with pain rated 3/10 and stable vital
signs
B. A 62-year-old client with heart failure who received 40mg IV furosemide 1 hour ago
and reports feeling "short of breath" [CORRECT]
C. A 28-year-old client admitted for observation after a mild concussion, alert and
oriented ×4
D. A 55-year-old client with diabetes mellitus requesting assistance with insulin injection
before breakfast
Correct Answer: B
Rationale: Using the ABCs (Airway, Breathing, Circulation) priority framework, Client B
presents with a potential breathing problem—"short of breath" after diuretic
administration suggests possible flash pulmonary edema or worsening heart failure,
which is life-threatening. The nurse must assess immediately to evaluate oxygenation
status and respiratory distress. Client A has controlled post-op pain (expected). Client C
is stable with resolved neuro status. Client D's request is important but not
urgent—insulin timing is flexible within a window. The distractor D represents a common
trap: diabetes management seems urgent, but ABCs always take precedence over
scheduled medications.
,Q2: A client with a central venous catheter (CVC) develops sudden dyspnea, chest pain,
and tachycardia during infusion of total parenteral nutrition (TPN). What is the nurse's
first action?
A. Stop the TPN infusion immediately [CORRECT]
B. Obtain a stat chest x-ray
C. Administer supplemental oxygen at 4L nasal cannula
D. Elevate the head of the bed to 90 degrees
Correct Answer: A
Rationale: These symptoms indicate potential air embolism or catheter-related
complication—immediately stopping the infusion prevents further air/fluid entry into the
circulation. While oxygen (C) and positioning (D) support respiratory status, stopping
the source is priority. Chest x-ray (B) is diagnostic but not immediate. The clinical
judgment pathway: recognize life-threatening complication → stop causative agent →
then implement supportive measures. Distractor C is a common second-priority
trap—oxygen is supportive but doesn't address the cause.
Q3: Which task is appropriate for the nurse to delegate to an unlicensed assistive
personnel (UAP)?
A. Assessing a postoperative client's incision for signs of infection
B. Obtaining a blood glucose reading on a stable diabetic client before mealtime
[CORRECT]
C. Teaching a newly diagnosed asthmatic client how to use a peak flow meter
D. Administering an oral antibiotic to a client with pneumonia
Correct Answer: B
Rationale: Delegation follows the "right task, right circumstance, right person, right
direction/communication, right supervision" framework. Blood glucose monitoring on a
,stable client is a routine, repetitive task with predictable outcomes that UAPs are trained
to perform. Assessment (A), teaching (C), and medication administration (D) require
nursing judgment, education, or licensure and cannot be delegated. Distractor A is a
frequent error—UAPs can report observations but cannot perform clinical assessments
requiring interpretation.
Q4: The nurse enters a client's room and finds the client unconscious on the floor
beside the bed. The bed alarm was not activated. What is the priority nursing action?
A. Call for help and activate the rapid response team
B. Assess the client's airway, breathing, and circulation [CORRECT]
C. Document the incident in the electronic health record
D. Return the client to bed using a lift device
Correct Answer: B
Rationale: The ABCs of emergency assessment apply—before moving the client or
calling codes, the nurse must determine if the client is breathing and has a pulse. This
30-second assessment determines whether CPR or emergency protocols are needed.
Calling for help (A) is appropriate but assessment comes first (you cannot effectively
communicate the emergency level without knowing the client's status). Documentation
(C) and repositioning (D) are never priorities over life-safety assessment. Distractor A
represents the "call for help first" trap—while important, the nurse must assess before
acting.
Q5: A client is prescribed contact isolation for methicillin-resistant Staphylococcus
aureus (MRSA) wound infection. Which action by the nurse demonstrates appropriate
infection control?
A. Wearing an N95 respirator when entering the room
, B. Performing hand hygiene with alcohol-based sanitizer before donning gloves
[CORRECT]
C. Placing the client in a negative pressure room
D. Wearing a gown only when changing the wound dressing
Correct Answer: B
Rationale: Contact isolation requires gloves and gown for room entry, with hand hygiene
before donning and after doffing PPE. Alcohol-based sanitizer is appropriate for hand
hygiene unless hands are visibly soiled. N95 respirators (A) are for airborne precautions.
Negative pressure (C) is for airborne isolation (TB, measles, varicella). Gowns are
required for all room entry (D), not just dressing changes. Distractor D represents a
common shortcut error—standard precautions require consistent PPE use, not
task-selective application.
Q6: The nurse is preparing to administer medications to four clients. Which situation
requires immediate intervention by the nurse?
A. A client with penicillin allergy prescribed azithromycin for respiratory infection
B. A client with a potassium level of 3.2 mEq/L prescribed furosemide 20mg PO
[CORRECT]
C. A client with blood pressure 138/88 prescribed hydrochlorothiazide 25mg PO
D. A client with heart rate 58 bpm prescribed metoprolol 50mg PO
Correct Answer: B
Rationale: Potassium 3.2 mEq/L indicates hypokalemia (normal 3.5-5.0). Furosemide is
a potassium-wasting diuretic that will further deplete potassium, risking dangerous
arrhythmias. The nurse must hold the medication and contact the provider.
Azithromycin (A) is appropriate for penicillin-allergic clients (different drug class). BP
138/88 (C) is mildly elevated—hydrochlorothiazide is appropriate. HR 58 (D) is
low-normal; while caution is warranted with beta-blockers, it's not an absolute
