NUR 104 HESI Foundations of Nursing Review
V2 Official Practice Exam Actual Exam
2026/2027 with Detailed Rationales | Complete
Exam-Style Questions | Pass Guaranteed – A+
Graded
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SECTION 1: FUNDAMENTALS OF NURSING PRACTICE Q1 – Q10
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Question 1 of 50
A 68-year-old client is admitted to the medical-surgical unit with a new diagnosis of heart
failure. During the initial assessment, the client states, "I don't understand why I'm here. My
doctor never explained anything to me." The nurse recognizes this statement as an indication
of which priority nursing concern?
A. Impaired coping related to hospitalization
B. Anxiety related to unfamiliar environment
C. Deficient knowledge related to disease process ✓ CORRECT
D. Ineffective health maintenance related to noncompliance
Correct Answer: C
Rationale: The client's direct statement about not understanding their diagnosis indicates a
knowledge deficit, which is the priority nursing diagnosis according to Maslow's hierarchy
and HESI prioritization standards. While anxiety and impaired coping may coexist, the root
cause is the lack of information about their condition, making deficient knowledge the most
accurate and priority diagnosis. On HESI exams, always listen for the client's own words to
identify the primary concern before selecting secondary emotional responses.
Question 2 of 50
A nurse on the postoperative unit is caring for a 45-year-old client who had abdominal surgery
8 hours ago. The client reports pain rated 7/10 and has not yet passed flatus. The nurse
administers the prescribed morphine 4 mg IV and returns 30 minutes later to find the client
drowsy but still reporting pain at 6/10. What is the nurse's priority action?
A. Reassess the client in another 30 minutes for pain relief
,B. Notify the provider to request a stronger analgesic
C. Encourage the client to use the incentive spirometer
D. Evaluate for other causes of pain such as abdominal distension or bladder retention ✓
CORRECT
Correct Answer: D
Rationale: Before escalating opioid therapy, the nurse must first assess for non-surgical
causes of persistent pain, such as urinary retention or paralytic ileus, which are common
postoperative complications that worsen with additional sedation. Simply increasing
analgesia without reassessment could mask a serious complication and delay appropriate
intervention. HESI emphasizes that thorough reassessment is the critical step between
intervention and further action in the nursing process.
Question 3 of 50
A nursing student is preparing to administer a scheduled 0900 medication to a client in a
long-term care facility. The student checks the medication administration record and notices
the medication is listed as "hold if systolic BP below 100 mmHg." The client's blood pressure
is 98/62 mmHg. What is the student's most appropriate action?
A. Administer the medication and recheck the blood pressure in 1 hour
B. Hold the medication and notify the charge nurse ✓ CORRECT
C. Recheck the blood pressure using the other arm before deciding
D. Give half the dose to avoid hypotensive effects
Correct Answer: B
Rationale: When a medication has a specific parameter for administration, the nurse must
hold the dose when parameters are not met and notify the appropriate personnel per facility
protocol and scope of practice. Attempting to administer, split the dose, or recheck without
guidance exceeds the student's authority and violates safe medication administration
principles. HESI consistently tests whether students recognize when to hold medications and
seek guidance rather than making independent clinical judgments beyond their scope.
Question 4 of 50
A 72-year-old client with diabetes is being discharged home after a 5-day hospitalization for
pneumonia. The nurse is providing discharge teaching about managing blood glucose at
home. The client nods and says, "I understand everything," but avoids eye contact and fidgets
with the discharge papers. What is the nurse's best response?
A. "Great, I'll have you sign the discharge instructions and you can go."
B. "I notice you seem a little unsure. Can you show me how you'll check your blood sugar?" ✓
CORRECT
C. "Don't worry, your family will help you figure it out at home."
, D. "Would you like me to call your doctor to extend your stay?"
Correct Answer: B
Rationale: Nonverbal cues such as avoiding eye contact and fidgeting often indicate anxiety
or lack of understanding despite verbal agreement, so the nurse should use the teach-back
method to confirm actual comprehension. This approach validates the client's feelings while
objectively assessing learning, which is a Joint Commission standard for effective discharge
teaching. HESI exams frequently test recognition of nonverbal communication cues and the
appropriate use of return demonstration to verify client understanding.
Question 5 of 50
A nurse is caring for a client who is Jehovah's Witness and requires emergency surgery after
a motor vehicle accident. The client is alert and oriented and refuses blood transfusion based
on religious beliefs. The client's spouse insists the nurse administer blood products to save
the client's life. What is the nurse's priority action?
A. Follow the spouse's wishes since the client may be in shock and not thinking clearly
B. Administer blood products under implied consent for emergency care
C. Honor the client's autonomous decision and document the refusal ✓ CORRECT
D. Contact the hospital ethics committee to override the client's decision
Correct Answer: C
Rationale: An alert and oriented adult client has the legal right to refuse treatment based on
religious beliefs, and the nurse must respect this autonomous decision while thoroughly
documenting the informed refusal in the medical record. The spouse cannot override a
competent client's wishes, and the ethics committee does not have authority to force
treatment against a competent adult's will. HESI prioritization questions on ethics
consistently emphasize that client autonomy takes precedence when the client is competent,
alert, and making an informed decision.
Question 6 of 50
A nurse enters a client's room and finds the client on the floor next to the bed. The client
states, "I tried to get to the bathroom by myself." The nurse completes a head-to-toe
assessment and finds no injuries. What is the nurse's priority action after ensuring client
safety?
A. Help the client back into bed and document the incident
B. Complete an incident report and notify the risk management department
C. Reassess the client for injuries and implement fall precautions ✓ CORRECT
D. Call the provider to order x-rays of the client's extremities
Correct Answer: C
V2 Official Practice Exam Actual Exam
2026/2027 with Detailed Rationales | Complete
Exam-Style Questions | Pass Guaranteed – A+
Graded
══════════════════════════════════════
SECTION 1: FUNDAMENTALS OF NURSING PRACTICE Q1 – Q10
══════════════════════════════════════
Question 1 of 50
A 68-year-old client is admitted to the medical-surgical unit with a new diagnosis of heart
failure. During the initial assessment, the client states, "I don't understand why I'm here. My
doctor never explained anything to me." The nurse recognizes this statement as an indication
of which priority nursing concern?
A. Impaired coping related to hospitalization
B. Anxiety related to unfamiliar environment
C. Deficient knowledge related to disease process ✓ CORRECT
D. Ineffective health maintenance related to noncompliance
Correct Answer: C
Rationale: The client's direct statement about not understanding their diagnosis indicates a
knowledge deficit, which is the priority nursing diagnosis according to Maslow's hierarchy
and HESI prioritization standards. While anxiety and impaired coping may coexist, the root
cause is the lack of information about their condition, making deficient knowledge the most
accurate and priority diagnosis. On HESI exams, always listen for the client's own words to
identify the primary concern before selecting secondary emotional responses.
Question 2 of 50
A nurse on the postoperative unit is caring for a 45-year-old client who had abdominal surgery
8 hours ago. The client reports pain rated 7/10 and has not yet passed flatus. The nurse
administers the prescribed morphine 4 mg IV and returns 30 minutes later to find the client
drowsy but still reporting pain at 6/10. What is the nurse's priority action?
A. Reassess the client in another 30 minutes for pain relief
,B. Notify the provider to request a stronger analgesic
C. Encourage the client to use the incentive spirometer
D. Evaluate for other causes of pain such as abdominal distension or bladder retention ✓
CORRECT
Correct Answer: D
Rationale: Before escalating opioid therapy, the nurse must first assess for non-surgical
causes of persistent pain, such as urinary retention or paralytic ileus, which are common
postoperative complications that worsen with additional sedation. Simply increasing
analgesia without reassessment could mask a serious complication and delay appropriate
intervention. HESI emphasizes that thorough reassessment is the critical step between
intervention and further action in the nursing process.
Question 3 of 50
A nursing student is preparing to administer a scheduled 0900 medication to a client in a
long-term care facility. The student checks the medication administration record and notices
the medication is listed as "hold if systolic BP below 100 mmHg." The client's blood pressure
is 98/62 mmHg. What is the student's most appropriate action?
A. Administer the medication and recheck the blood pressure in 1 hour
B. Hold the medication and notify the charge nurse ✓ CORRECT
C. Recheck the blood pressure using the other arm before deciding
D. Give half the dose to avoid hypotensive effects
Correct Answer: B
Rationale: When a medication has a specific parameter for administration, the nurse must
hold the dose when parameters are not met and notify the appropriate personnel per facility
protocol and scope of practice. Attempting to administer, split the dose, or recheck without
guidance exceeds the student's authority and violates safe medication administration
principles. HESI consistently tests whether students recognize when to hold medications and
seek guidance rather than making independent clinical judgments beyond their scope.
Question 4 of 50
A 72-year-old client with diabetes is being discharged home after a 5-day hospitalization for
pneumonia. The nurse is providing discharge teaching about managing blood glucose at
home. The client nods and says, "I understand everything," but avoids eye contact and fidgets
with the discharge papers. What is the nurse's best response?
A. "Great, I'll have you sign the discharge instructions and you can go."
B. "I notice you seem a little unsure. Can you show me how you'll check your blood sugar?" ✓
CORRECT
C. "Don't worry, your family will help you figure it out at home."
, D. "Would you like me to call your doctor to extend your stay?"
Correct Answer: B
Rationale: Nonverbal cues such as avoiding eye contact and fidgeting often indicate anxiety
or lack of understanding despite verbal agreement, so the nurse should use the teach-back
method to confirm actual comprehension. This approach validates the client's feelings while
objectively assessing learning, which is a Joint Commission standard for effective discharge
teaching. HESI exams frequently test recognition of nonverbal communication cues and the
appropriate use of return demonstration to verify client understanding.
Question 5 of 50
A nurse is caring for a client who is Jehovah's Witness and requires emergency surgery after
a motor vehicle accident. The client is alert and oriented and refuses blood transfusion based
on religious beliefs. The client's spouse insists the nurse administer blood products to save
the client's life. What is the nurse's priority action?
A. Follow the spouse's wishes since the client may be in shock and not thinking clearly
B. Administer blood products under implied consent for emergency care
C. Honor the client's autonomous decision and document the refusal ✓ CORRECT
D. Contact the hospital ethics committee to override the client's decision
Correct Answer: C
Rationale: An alert and oriented adult client has the legal right to refuse treatment based on
religious beliefs, and the nurse must respect this autonomous decision while thoroughly
documenting the informed refusal in the medical record. The spouse cannot override a
competent client's wishes, and the ethics committee does not have authority to force
treatment against a competent adult's will. HESI prioritization questions on ethics
consistently emphasize that client autonomy takes precedence when the client is competent,
alert, and making an informed decision.
Question 6 of 50
A nurse enters a client's room and finds the client on the floor next to the bed. The client
states, "I tried to get to the bathroom by myself." The nurse completes a head-to-toe
assessment and finds no injuries. What is the nurse's priority action after ensuring client
safety?
A. Help the client back into bed and document the incident
B. Complete an incident report and notify the risk management department
C. Reassess the client for injuries and implement fall precautions ✓ CORRECT
D. Call the provider to order x-rays of the client's extremities
Correct Answer: C
