HESI RN FUNDAMENTALS EXAM 2026
The nurse transcribes the postoperative prescriptions for a client who returns to the unit
followingtsurgerytandtnotestthattantantihypertensivetmedicationtthattwastprescribedtpreoperatively
tistnottlisted.tWhichtactiontshouldtthetnursettake?
A.
Consulttwithtthetpharmacisttabouttthetneedttotcontinuetthetmedication.
tB.
Administertthetantihypertensivetmedicationtastprescribedtpreoperatively.
tC.
Withholdtthetmedicationtuntiltthetclienttistfullytalerttandtvitaltsignstaretstable.
tD.
Contacttthethealthtcaretproviderttotrenewtthetprescriptiontfortthetmedication.t-tAnswer-D
Rationale:tMedicationstprescribedtpreoperativelytmusttbetrenewedtpostoperatively,tsotthetnursetsh
ouldtcontacttthethealthtcaretprovidertiftthetantihypertensivetmedicationtistnottincludedtintthetposto
perativetprescriptions.tThetpharmacisttdoestnottprescribetmedicationstortrenewtprescriptions.tThet
nursetmustthavetatcurrenttprescriptiontbeforetadministeringtanytmedications.
Whichtfluidtwilltthetnursetselectttotadministertwithtthetprescribedtbloodttransfusion?
A.
5%tDextrosetandtwater
tB.
Normaltsaline
tC.
LactatedtRingerstsolution
tD.
5%tDextrosetandtlactatedtringerst-tAnswer-Bt
Rationale:tNormaltsalinetsolutiontistthetonlytsolutiontthattistcompatibletwithtblood.
,Whentassistingtatclienttfromtthetbedttotatchair,twhichtproceduretistbesttfortthetnursettotfollow?
A.
Placetthetchairtparallelttotthetbed,twithtitstbackttowardtthetheadtoftthetbedtandtassisttthetclienttintm
ovingttotthetchair.
tB.
Withtthetnurse'stfeettspreadtaparttandtkneestalignedtwithtthetclient'stknees,tstandtandtpivottthetclien
ttintotthetchair.
tC.
Assisttthetclientttotatstandingtpositiontbytgentlytliftingtupward,tunderneathtthetaxillae.
tD.
Standtbesidetthetclient,tplacetthetclient'starmstaroundtthetnurse'stneck,tandtgentlytmovetthetclienttto
tthetchair.t-tAnswer-B
Rationale:tOptiontBtdescribestthetcorrecttpositioningtoftthetnursetandtaffordstthetnursetatwidetbaset
oftsupporttwhiletstabilizingtthetclient'stkneestwhentassistingttotatstandingtposition.tThetchairtshoul
dtbetplacedtattat45-
degreetanglettotthetbed,twithtthetbacktoftthetchairttowardtthetheadtoftthetbed.tClientstshouldtnevert
betliftedtundertthetaxillae;tthistcouldtdamagetnervestandtstraintthetnurse'stback.tThetclienttshouldtb
etinstructedttotusetthetarmstoftthetchairtandtshouldtnevertplacethistorthertarmstaroundtthetnurse'stne
ck;tthistplacestunduetstresstontthetnurse'stnecktandtbacktandtincreasestthetrisktfortatfall.
Thetnursetistcalledttotthetwaitingtroomtoftatpediatrictclinic.tThetfrantictmothertstates,t"Itthinktmyt4
-month-oldtbabytistchoking!"tWhattstepstwilltthetnursettake?t(Selecttalltthattapply.)
A.
Compresstthetchesttoncetbetweentthetnipplestwithttwotfingers.
tB.
Notetanytobstructiontortabsencetoftbreathing.
tC.
Delivertfivetbackslapstbetweentthetshouldertblades.
tD.
Placetthetinfanttovertthetnurse'starm.
tE.
Performtatblindtfingertsweep.t-tAnswer-B,tC,tD
,Rationale:tThetfingerstaretplacedtattthetsametlocationtontantinfanttastchesttcompressionstfortCPR;t
however,tthetnursetmusttdelivertfivetchesttthrusts,taftertthetfivetbacktslaps.tBlindtsweepstaretnottus
edtastthistactiontmaytpushtthetobjecttdeepertintotthetthroat.tThetremainingtstepstaretcorrect.
HowtmanytmLtwilltthetnursetdocumenttontthetclient'stintaketandtoutputtrecordtfromtthetitemstliste
d?t_____tmL
1200tmLtwater
4touncetcontainertoftgelatin
8touncestoftorangetjuice
355tmLtcantoftsoda1tcuptoftsoupt-tAnswer-Answer:t2155
Rationale:t1200t+t240t(8toz)t+t240t(1tcup)t+t120t(4toz)t+t355t=t2155
ThetnursetobservestatUAPttakingtatclient'stbloodtpressuretintthetlowertextremity.tWhichtobservatio
ntoftthistproceduretrequirestthetnursettotintervenetwithtthetUAP'stapproach?
A.
Thetcufftwrapstaroundtthetgirthtoftthetleg.
tB.
ThetUAPtauscultatestthetpoplitealtpulsetwithtthetcufftontthetlowertleg.
tC.
Thetclienttistplacedtintatpronetposition.
tD.
Thetsystolictreadingtist20tmmtHgthighertthantthetbloodtpressuretintthetclient'starm.t-tAnswer-B
Rationale:tWhentobtainingtthetbloodtpressuretintthetlowertextremities,tthetpoplitealtpulsetistthetsite
tfortauscultationtwhentthetbloodtpressuretcufftistappliedtaroundtthetthigh.tThetnursetshouldtinterve
netwithtthetUAPtwhothastappliedtthetcufftontthetlowertleg.tOptiontAtensurestantaccuratetassessme
nt,tandtoptiontCtprovidestthetbesttaccessttotthetartery.tSystolictpressuretintthetpoplitealtarterytistusu
allyt10ttot40tmmtHgthighertthantintthetbrachialtartery.
Duringtatclinictvisit,tthetmothertoftat7-year-
oldtreportsttotthetnursetthatthertchildtistoftentawaketuntiltmidnighttplayingtandtistthentverytdifficult
ttotawakentintthetmorningtfortschool.tWhichtassessmenttdatatshouldtthetnursetobtaintintresponsettot
thetmother'stconcern?
, A.
Thetoccurrencetoftanytepisodestoftsleeptapnea
tB.
Thetchild'stbloodtpressure,tpulse,tandtrespirations
tC.
Lengthtoftrapidteyetmovementt(REM)tsleeptthattthetchildtistexperiencing
tD.
Descriptiontoftthetfamily'sthometenvironmentt-tAnswer-D
Rationale:tSchool-
agetchildrentoftentresisttbedtime.tThetnursetshouldtbegintbytassessingtthetenvironmenttoftthethome
ttotdeterminetfactorstthattmaytnottbetconducivettotthetestablishmenttoftbedtimetritualstthattpromote
tsleep.tOptiontAtoftentcausestdaytimetfatiguetrathertthantresistancettotgoingttotsleep.tOptiontBtistu
nlikelyttotprovidetusefultdata.tThetnursetcannottdeterminetoptiontC.
Thetnursetidentifiestatpotentialtfortinfectiontintatclienttwithtpartial-thicknesst(second-
degree)tandtfull-thicknesst(third-
degree)tburns.tWhattactionthastthethighesttprioritytintdecreasingtthetclient'strisktoftinfection?
A.
Administrationtoftplasmatexpanders
tB.
Usetoftcarefulthandwashingttechnique
tC.
Applicationtoftattopicaltantibacterialtcream
tD.
Limitingtvisitorsttotthetclienttwithtburnst-tAnswer-B
Rationale:tCarefulthandwashingttechniquetistthetsingletmostteffectivetinterventiontfortthetpreventi
ontoftcontaminationttotalltclients.tOptiontAtreversestthethypovolemiatthattinitiallytaccompaniestbu
rnttraumatbuttistnottrelatedttotdecreasingtthetproliferationtoftinfectivetorganisms.tOptionstCtandtDt
aretrecommendedtbytvarioustburntcenterstastpossibletwaysttotreducetthetchancetoftinfection.tOptio
ntBtistatproventtechniquettotpreventtinfection.
The nurse transcribes the postoperative prescriptions for a client who returns to the unit
followingtsurgerytandtnotestthattantantihypertensivetmedicationtthattwastprescribedtpreoperatively
tistnottlisted.tWhichtactiontshouldtthetnursettake?
A.
Consulttwithtthetpharmacisttabouttthetneedttotcontinuetthetmedication.
tB.
Administertthetantihypertensivetmedicationtastprescribedtpreoperatively.
tC.
Withholdtthetmedicationtuntiltthetclienttistfullytalerttandtvitaltsignstaretstable.
tD.
Contacttthethealthtcaretproviderttotrenewtthetprescriptiontfortthetmedication.t-tAnswer-D
Rationale:tMedicationstprescribedtpreoperativelytmusttbetrenewedtpostoperatively,tsotthetnursetsh
ouldtcontacttthethealthtcaretprovidertiftthetantihypertensivetmedicationtistnottincludedtintthetposto
perativetprescriptions.tThetpharmacisttdoestnottprescribetmedicationstortrenewtprescriptions.tThet
nursetmustthavetatcurrenttprescriptiontbeforetadministeringtanytmedications.
Whichtfluidtwilltthetnursetselectttotadministertwithtthetprescribedtbloodttransfusion?
A.
5%tDextrosetandtwater
tB.
Normaltsaline
tC.
LactatedtRingerstsolution
tD.
5%tDextrosetandtlactatedtringerst-tAnswer-Bt
Rationale:tNormaltsalinetsolutiontistthetonlytsolutiontthattistcompatibletwithtblood.
,Whentassistingtatclienttfromtthetbedttotatchair,twhichtproceduretistbesttfortthetnursettotfollow?
A.
Placetthetchairtparallelttotthetbed,twithtitstbackttowardtthetheadtoftthetbedtandtassisttthetclienttintm
ovingttotthetchair.
tB.
Withtthetnurse'stfeettspreadtaparttandtkneestalignedtwithtthetclient'stknees,tstandtandtpivottthetclien
ttintotthetchair.
tC.
Assisttthetclientttotatstandingtpositiontbytgentlytliftingtupward,tunderneathtthetaxillae.
tD.
Standtbesidetthetclient,tplacetthetclient'starmstaroundtthetnurse'stneck,tandtgentlytmovetthetclienttto
tthetchair.t-tAnswer-B
Rationale:tOptiontBtdescribestthetcorrecttpositioningtoftthetnursetandtaffordstthetnursetatwidetbaset
oftsupporttwhiletstabilizingtthetclient'stkneestwhentassistingttotatstandingtposition.tThetchairtshoul
dtbetplacedtattat45-
degreetanglettotthetbed,twithtthetbacktoftthetchairttowardtthetheadtoftthetbed.tClientstshouldtnevert
betliftedtundertthetaxillae;tthistcouldtdamagetnervestandtstraintthetnurse'stback.tThetclienttshouldtb
etinstructedttotusetthetarmstoftthetchairtandtshouldtnevertplacethistorthertarmstaroundtthetnurse'stne
ck;tthistplacestunduetstresstontthetnurse'stnecktandtbacktandtincreasestthetrisktfortatfall.
Thetnursetistcalledttotthetwaitingtroomtoftatpediatrictclinic.tThetfrantictmothertstates,t"Itthinktmyt4
-month-oldtbabytistchoking!"tWhattstepstwilltthetnursettake?t(Selecttalltthattapply.)
A.
Compresstthetchesttoncetbetweentthetnipplestwithttwotfingers.
tB.
Notetanytobstructiontortabsencetoftbreathing.
tC.
Delivertfivetbackslapstbetweentthetshouldertblades.
tD.
Placetthetinfanttovertthetnurse'starm.
tE.
Performtatblindtfingertsweep.t-tAnswer-B,tC,tD
,Rationale:tThetfingerstaretplacedtattthetsametlocationtontantinfanttastchesttcompressionstfortCPR;t
however,tthetnursetmusttdelivertfivetchesttthrusts,taftertthetfivetbacktslaps.tBlindtsweepstaretnottus
edtastthistactiontmaytpushtthetobjecttdeepertintotthetthroat.tThetremainingtstepstaretcorrect.
HowtmanytmLtwilltthetnursetdocumenttontthetclient'stintaketandtoutputtrecordtfromtthetitemstliste
d?t_____tmL
1200tmLtwater
4touncetcontainertoftgelatin
8touncestoftorangetjuice
355tmLtcantoftsoda1tcuptoftsoupt-tAnswer-Answer:t2155
Rationale:t1200t+t240t(8toz)t+t240t(1tcup)t+t120t(4toz)t+t355t=t2155
ThetnursetobservestatUAPttakingtatclient'stbloodtpressuretintthetlowertextremity.tWhichtobservatio
ntoftthistproceduretrequirestthetnursettotintervenetwithtthetUAP'stapproach?
A.
Thetcufftwrapstaroundtthetgirthtoftthetleg.
tB.
ThetUAPtauscultatestthetpoplitealtpulsetwithtthetcufftontthetlowertleg.
tC.
Thetclienttistplacedtintatpronetposition.
tD.
Thetsystolictreadingtist20tmmtHgthighertthantthetbloodtpressuretintthetclient'starm.t-tAnswer-B
Rationale:tWhentobtainingtthetbloodtpressuretintthetlowertextremities,tthetpoplitealtpulsetistthetsite
tfortauscultationtwhentthetbloodtpressuretcufftistappliedtaroundtthetthigh.tThetnursetshouldtinterve
netwithtthetUAPtwhothastappliedtthetcufftontthetlowertleg.tOptiontAtensurestantaccuratetassessme
nt,tandtoptiontCtprovidestthetbesttaccessttotthetartery.tSystolictpressuretintthetpoplitealtarterytistusu
allyt10ttot40tmmtHgthighertthantintthetbrachialtartery.
Duringtatclinictvisit,tthetmothertoftat7-year-
oldtreportsttotthetnursetthatthertchildtistoftentawaketuntiltmidnighttplayingtandtistthentverytdifficult
ttotawakentintthetmorningtfortschool.tWhichtassessmenttdatatshouldtthetnursetobtaintintresponsettot
thetmother'stconcern?
, A.
Thetoccurrencetoftanytepisodestoftsleeptapnea
tB.
Thetchild'stbloodtpressure,tpulse,tandtrespirations
tC.
Lengthtoftrapidteyetmovementt(REM)tsleeptthattthetchildtistexperiencing
tD.
Descriptiontoftthetfamily'sthometenvironmentt-tAnswer-D
Rationale:tSchool-
agetchildrentoftentresisttbedtime.tThetnursetshouldtbegintbytassessingtthetenvironmenttoftthethome
ttotdeterminetfactorstthattmaytnottbetconducivettotthetestablishmenttoftbedtimetritualstthattpromote
tsleep.tOptiontAtoftentcausestdaytimetfatiguetrathertthantresistancettotgoingttotsleep.tOptiontBtistu
nlikelyttotprovidetusefultdata.tThetnursetcannottdeterminetoptiontC.
Thetnursetidentifiestatpotentialtfortinfectiontintatclienttwithtpartial-thicknesst(second-
degree)tandtfull-thicknesst(third-
degree)tburns.tWhattactionthastthethighesttprioritytintdecreasingtthetclient'strisktoftinfection?
A.
Administrationtoftplasmatexpanders
tB.
Usetoftcarefulthandwashingttechnique
tC.
Applicationtoftattopicaltantibacterialtcream
tD.
Limitingtvisitorsttotthetclienttwithtburnst-tAnswer-B
Rationale:tCarefulthandwashingttechniquetistthetsingletmostteffectivetinterventiontfortthetpreventi
ontoftcontaminationttotalltclients.tOptiontAtreversestthethypovolemiatthattinitiallytaccompaniestbu
rnttraumatbuttistnottrelatedttotdecreasingtthetproliferationtoftinfectivetorganisms.tOptionstCtandtDt
aretrecommendedtbytvarioustburntcenterstastpossibletwaysttotreducetthetchancetoftinfection.tOptio
ntBtistatproventtechniquettotpreventtinfection.
