HESI FUNDAMENTALS V.2 QUESTIONS AND ANSWERS WITH COMPLETE SOLUTIONS |
NEW UPDATE 2026 | 100% CORRECT
Question 1
The nurse observes a newly admitted older adult female take short steps and walk very slowly
while pushing a walker in front of her. What action should the nurse take in response to these
observations?
A) Teach the client to take longer steps at a faster pace.
B) Suggest that the client use a wheelchair instead of a walker.
C) Place the client on bedrest until the healthcare provider is notified.
D) Complete a full fall risk assessment of the client.
E) Provide the client with a cane to see if her gait improves.
Correct Answer: D) Complete a full fall risk assessment of the client.
Rationale: Safety is the priority when a gait abnormality is observed. Short, slow steps while
using a walker indicate a potential for instability. A comprehensive fall risk assessment
(using a tool like the Morse Fall Scale) is the first step in implementing individualized
safety precautions.
Question 2
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation
remains at 94%, which is the same reading obtained prior to starting the procedure. What action
should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth.
E) Increase the suction pressure to finish the procedure faster.
Correct Answer: C) Complete the intermittent suction of the nasopharynx.
Rationale: If the client's oxygen saturation remains stable at their baseline during the
procedure, it is safe to complete the necessary suctioning. Intermittent suctioning prevents
prolonged hypoxia and mucosal damage while effectively clearing the airway.
Question 3
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert,
oriented, and requests that no heroic measures be implemented if her breathing stops. What
action should the nurse take first?
A) Discuss with the client her meaning of "heroic measures."
B) Obtain a "do not resuscitate" (DNR) prescription immediately.
C) Set up a family conference to discuss the client’s wishes.
D) Consult the palliative care team about the client's care.
E) Inform the client that heroic measures are required by law.
Correct Answer: A) Discuss with the client her meaning of heroic measures.
Rationale: Before clinical or legal steps are taken, the nurse must clarify the client’s
, 2
understanding of "heroic measures." Terms like this are subjective; the client may mean
she refuses intubation but would allow chemical resuscitation, or vice versa. Assessment of
the client's values must come first.
Question 4
A client diagnosed with primary open-angle glaucoma receives a prescription for biotic eye
drops, pilocarpine HCl. What instruction should the nurse plan to include in this client's
teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops."
E) "Stop taking the drops if your vision becomes slightly blurred."
Correct Answer: A) "Do not allow the dropper bottle to touch the eye."
Rationale: To prevent contamination of the medication bottle and the potential for eye
infection, the tip of the dropper must never touch the eye, eyelashes, or any other surface.
This is a standard principle of ophthalmic medication administration.
Question 5
When assessing a client who starts to wheeze, what related data should the nurse obtain first?
A) Heart sounds.
B) Body temperature.
C) Presence of radiation.
D) Precipitating factors.
E) History of childhood immunizations.
Correct Answer: D) Precipitating factors.
Rationale: Wheezing is a sign of airway narrowing. Identifying what triggered the event
(precipitating factors)—such as exposure to an allergen, exercise, or smoke—is essential for
determining the appropriate intervention and preventing further respiratory distress.
Question 6
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which
client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to
provide routine foot care? (Select all that apply)
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
Correct Answer: A, B, C) Syncope when bending; Hand tremors; Diminished visual acuity.
Rationale: Foot care requires the ability to see clearly, hold tools steadily, and bend over
, 3
safely. Syncope, tremors, and poor vision increase the risk of injury if the client attempts
self-care. Incontinence and gait do not directly affect the physical ability to perform foot
care.
Question 7
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client's risk for infection?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
E) Clean the urinary meatus with antiseptic wipes every 4 hours.
Correct Answer: B) Encourage increased intake of oral fluids.
Rationale: Increased fluid intake promotes urine production, which provides a "natural"
flushing of the bladder and tubing, reducing the stasis of bacteria and decreasing the risk
of Catheter-Associated Urinary Tract Infections (CAUTI).
Question 8
To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
E) Check the client’s vital signs for tachycardia.
Correct Answer: C) Ask the client to describe the pain.
Rationale: The "quality" of pain refers to how it feels (e.g., sharp, dull, burning, throbbing).
The only way to obtain this subjective data is to ask the client to describe the sensation in
their own words.
Question 9
A client diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do
not have long to live." Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
E) "Everything will be fine; the doctors are often wrong."
Correct Answer: D) "Yes, your condition is serious."
Rationale: This response acknowledges the reality of the client’s statement without being
overly blunt or offering false hope. It provides an opening for the client to express their
feelings further (therapeutic communication).
, 4
Question 10
When performing blood pressure measurement to assess for orthostatic hypotension, which
action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at the bedside.
E) Inflate the cuff to 200 mmHg.
Correct Answer: C) Position the client supine for a few minutes.
Rationale: The procedure for orthostatic vitals begins with the client in a supine position for
3–10 minutes to establish a baseline reading before moving to sitting and standing
positions.
Question 11
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client
who is unconscious. After supporting the client's knee with one hand, what action should the
nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel.
E) Rotate the hip externally.
Correct Answer: D) Cradle the client's heel.
Rationale: When performing passive ROM, the nurse must support the joint properly. For
the leg, the nurse supports the knee with one hand and cradles the heel with the other to
ensure the limb is stable before beginning the movement.
Question 12
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
What action should the nurse take after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution.
E) Clean the meatus with betadine.
Correct Answer: B) Draw up the irrigating solution into the syringe.
Rationale: In the sequence of an open irrigation procedure, once the nurse has donned
gloves (sterile if indicated by policy), the next logical step is to prepare the equipment by
drawing up the prescribed amount of irrigation solution into the syringe.
NEW UPDATE 2026 | 100% CORRECT
Question 1
The nurse observes a newly admitted older adult female take short steps and walk very slowly
while pushing a walker in front of her. What action should the nurse take in response to these
observations?
A) Teach the client to take longer steps at a faster pace.
B) Suggest that the client use a wheelchair instead of a walker.
C) Place the client on bedrest until the healthcare provider is notified.
D) Complete a full fall risk assessment of the client.
E) Provide the client with a cane to see if her gait improves.
Correct Answer: D) Complete a full fall risk assessment of the client.
Rationale: Safety is the priority when a gait abnormality is observed. Short, slow steps while
using a walker indicate a potential for instability. A comprehensive fall risk assessment
(using a tool like the Morse Fall Scale) is the first step in implementing individualized
safety precautions.
Question 2
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation
remains at 94%, which is the same reading obtained prior to starting the procedure. What action
should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth.
E) Increase the suction pressure to finish the procedure faster.
Correct Answer: C) Complete the intermittent suction of the nasopharynx.
Rationale: If the client's oxygen saturation remains stable at their baseline during the
procedure, it is safe to complete the necessary suctioning. Intermittent suctioning prevents
prolonged hypoxia and mucosal damage while effectively clearing the airway.
Question 3
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert,
oriented, and requests that no heroic measures be implemented if her breathing stops. What
action should the nurse take first?
A) Discuss with the client her meaning of "heroic measures."
B) Obtain a "do not resuscitate" (DNR) prescription immediately.
C) Set up a family conference to discuss the client’s wishes.
D) Consult the palliative care team about the client's care.
E) Inform the client that heroic measures are required by law.
Correct Answer: A) Discuss with the client her meaning of heroic measures.
Rationale: Before clinical or legal steps are taken, the nurse must clarify the client’s
, 2
understanding of "heroic measures." Terms like this are subjective; the client may mean
she refuses intubation but would allow chemical resuscitation, or vice versa. Assessment of
the client's values must come first.
Question 4
A client diagnosed with primary open-angle glaucoma receives a prescription for biotic eye
drops, pilocarpine HCl. What instruction should the nurse plan to include in this client's
teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops."
E) "Stop taking the drops if your vision becomes slightly blurred."
Correct Answer: A) "Do not allow the dropper bottle to touch the eye."
Rationale: To prevent contamination of the medication bottle and the potential for eye
infection, the tip of the dropper must never touch the eye, eyelashes, or any other surface.
This is a standard principle of ophthalmic medication administration.
Question 5
When assessing a client who starts to wheeze, what related data should the nurse obtain first?
A) Heart sounds.
B) Body temperature.
C) Presence of radiation.
D) Precipitating factors.
E) History of childhood immunizations.
Correct Answer: D) Precipitating factors.
Rationale: Wheezing is a sign of airway narrowing. Identifying what triggered the event
(precipitating factors)—such as exposure to an allergen, exercise, or smoke—is essential for
determining the appropriate intervention and preventing further respiratory distress.
Question 6
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which
client assessment findings indicate the need to assign unlicensed assistive personnel (UAP) to
provide routine foot care? (Select all that apply)
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
Correct Answer: A, B, C) Syncope when bending; Hand tremors; Diminished visual acuity.
Rationale: Foot care requires the ability to see clearly, hold tools steadily, and bend over
, 3
safely. Syncope, tremors, and poor vision increase the risk of injury if the client attempts
self-care. Incontinence and gait do not directly affect the physical ability to perform foot
care.
Question 7
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client's risk for infection?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
E) Clean the urinary meatus with antiseptic wipes every 4 hours.
Correct Answer: B) Encourage increased intake of oral fluids.
Rationale: Increased fluid intake promotes urine production, which provides a "natural"
flushing of the bladder and tubing, reducing the stasis of bacteria and decreasing the risk
of Catheter-Associated Urinary Tract Infections (CAUTI).
Question 8
To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
E) Check the client’s vital signs for tachycardia.
Correct Answer: C) Ask the client to describe the pain.
Rationale: The "quality" of pain refers to how it feels (e.g., sharp, dull, burning, throbbing).
The only way to obtain this subjective data is to ask the client to describe the sensation in
their own words.
Question 9
A client diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do
not have long to live." Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
E) "Everything will be fine; the doctors are often wrong."
Correct Answer: D) "Yes, your condition is serious."
Rationale: This response acknowledges the reality of the client’s statement without being
overly blunt or offering false hope. It provides an opening for the client to express their
feelings further (therapeutic communication).
, 4
Question 10
When performing blood pressure measurement to assess for orthostatic hypotension, which
action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at the bedside.
E) Inflate the cuff to 200 mmHg.
Correct Answer: C) Position the client supine for a few minutes.
Rationale: The procedure for orthostatic vitals begins with the client in a supine position for
3–10 minutes to establish a baseline reading before moving to sitting and standing
positions.
Question 11
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client
who is unconscious. After supporting the client's knee with one hand, what action should the
nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel.
E) Rotate the hip externally.
Correct Answer: D) Cradle the client's heel.
Rationale: When performing passive ROM, the nurse must support the joint properly. For
the leg, the nurse supports the knee with one hand and cradles the heel with the other to
ensure the limb is stable before beginning the movement.
Question 12
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
What action should the nurse take after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution.
E) Clean the meatus with betadine.
Correct Answer: B) Draw up the irrigating solution into the syringe.
Rationale: In the sequence of an open irrigation procedure, once the nurse has donned
gloves (sterile if indicated by policy), the next logical step is to prepare the equipment by
drawing up the prescribed amount of irrigation solution into the syringe.
