Fundamentals Hesi Practice Test Bank with
a Review of 220 Questions and Correct
Detailed Answers / Hesi Fundamentals
Practice Test (New!)
Section 1: Safe and Effective Care Environment - 45 Questions
Question 1: A nurse is preparing to administer medications to a client. Which of the following actions is
the priority before administering the medication?
A) Check the client's vital signs
B) Verify the client's identity using two identifiers
C) Review the medication's side effects
D) Assess the client's allergies
Answer: B) Verify the client's identity using two identifiers
Rationale: The priority action before any medication administration is verifying the client's identity using
two identifiers (e.g., name and date of birth) to ensure the right client receives the right medication. This
is a critical patient safety measure.
Question 2: A client is experiencing a seizure. Which of the following actions should the nurse take first?
A) Insert a padded tongue blade
B) Restrain the client's extremities
C) Move the client to a private room
D) Protect the client's head from injury
Answer: D) Protect the client's head from injury
Rationale: During a seizure, the priority is to protect the client from injury. Placing a hand or soft object
under the head prevents head trauma. Never insert anything into the mouth or restrain movements.
Question 3: A nurse is caring for a client who has a nasogastric tube. Which of the following actions is
appropriate to verify tube placement?
A) Aspirate gastric contents and check pH
B) Auscultate for air insufflation over the epigastric area
C) Observe the color of the aspirated fluid
D) Measure the length of the external tube
Answer: A) Aspirate gastric contents and check pH
Rationale: The most reliable method to verify NG tube placement is aspiration of gastric contents and pH
testing (pH should be ≤5). Auscultation (the "whoosh" test) is no longer considered reliable. X-ray is the
gold standard.
,Question 4: A nurse is preparing to discharge a client who is prescribed home oxygen therapy. Which of
the following instructions should the nurse include?
A) "Keep oxygen cylinders in a horizontal position"
B) "Apply petroleum-based ointment to nares"
C) "Post 'No Smoking' signs in your home"
D) "Increase oxygen flow during exercise"
Answer: C) "Post 'No Smoking' signs in your home"
Rationale: Oxygen is highly flammable. Clients and families must be educated about fire safety, including
posting "No Smoking" signs, avoiding open flames, and keeping oxygen away from heat sources.
Question 5: A nurse is performing a sterile dressing change. Which of the following actions maintains a
sterile field?
A) Placing the sterile drape with the shiny side down
B) Reaching over the sterile field to retrieve a dropped item
C) Opening the sterile package away from the body
D) Using sterile gloves that have been opened for 30 minutes
Answer: C) Opening the sterile package away from the body
Rationale: Opening the sterile package away from the body prevents contamination from the nurse's
clothing or body. The outer edge of the sterile field is also considered contaminated.
Question 6: A client is receiving a blood transfusion and develops sudden chills, fever, and flank pain.
The nurse should first:
A) Stop the transfusion
B) Slow the transfusion rate
C) Administer an antihistamine
D) Notify the provider
Answer: A) Stop the transfusion
Rationale: These symptoms indicate a possible hemolytic transfusion reaction. The nurse's priority is to
stop the transfusion immediately, disconnect the tubing, and maintain IV access with new tubing and
normal saline.
Question 7: A nurse is teaching a client about the use of a patient-controlled analgesia (PCA) pump.
Which of the following statements by the client indicates understanding?
A) "I will press the button every 15 minutes whether I have pain or not"
B) "My family can press the button if I am asleep"
C) "I should press the button when I feel pain"
D) "The pump will automatically deliver medication every hour"
Answer: C) "I should press the button when I feel pain"
Rationale: PCA pumps allow clients to self-administer pain medication when needed. The client should
press the button when pain is present. Only the client should press the button to prevent overdose.
Question 8: A client is placed in restraints. Which of the following actions is the nurse's priority?
A) Document the type of restraint used
B) Assess the client's vital signs
,C) Check the client's skin integrity and circulation every 2 hours
D) Obtain a provider's order within 24 hours
Answer: C) Check the client's skin integrity and circulation every 2 hours
Rationale: The priority is to monitor the client's safety and well-being. Skin integrity and circulation must
be assessed every 2 hours, and restraints should be removed for range of motion exercises.
Question 9: A nurse is assisting with a procedure that requires informed consent. Which of the following
clients is able to give informed consent?
A) A 17-year-old who is married
B) A 16-year-old who is emancipated
C) A client who is oriented and alert
D) A client who is under the influence of pain medication
Answer: C) A client who is oriented and alert
Rationale: Informed consent requires that the client be alert, oriented, and able to understand the risks,
benefits, and alternatives to the procedure. Emancipated minors may consent in some jurisdictions, but
the best answer is an alert, oriented adult client.
Question 10: A nurse is documenting client care. Which of the following is an appropriate
documentation entry?
A) "The client appears to be in pain"
B) "The client is faking symptoms"
C) "The client is confused and disoriented"
D) "The client reports chest pain rated 6/10"
Answer: D) "The client reports chest pain rated 6/10"
Rationale: Documentation should be objective, factual, and use direct quotes when possible. "Reports
chest pain rated 6/10" is objective and measurable. Opinions and judgments (appears, faking) are
inappropriate.
Question 11: A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions is most important for the nurse's safety?
A) Use the client's gait belt
B) Position the chair at a 45-degree angle
C) Place the bed in the lowest position
D) Assess the client's ability to bear weight
Answer: D) Assess the client's ability to bear weight
Rationale: Before any transfer, the nurse must assess the client's ability to bear weight and participate in
the transfer. This determines the type of transfer and equipment needed for safety.
Question 12: A client is prescribed a fall risk protocol. Which of the following interventions is
appropriate to include?
A) Keeping the bed in the highest position
B) Placing the call bell within reach
C) Using restraints at all times
D) Keeping the room lights dim
, Answer: B) Placing the call bell within reach
Rationale: For clients at risk for falls, the call bell should be within easy reach, the bed should be in the
lowest position, brakes locked, and nonskid socks should be worn. Restraints are a last resort.
Question 13: A nurse discovers a fire in a client's room. Which of the following actions should the nurse
take first?
A) Activate the fire alarm
B) Evacuate the client
C) Extinguish the fire
D) Close the door
Answer: B) Evacuate the client
Rationale: According to the RACE protocol (Rescue, Alarm, Contain, Extinguish), the nurse should first
rescue (evacuate) clients in immediate danger, then activate the alarm, contain the fire, and extinguish if
safe.
Question 14: A client with a hearing impairment has difficulty understanding discharge instructions.
Which of the following actions is most appropriate?
A) Speak loudly and slowly
B) Provide written instructions
C) Use hand gestures only
D) Ask a family member to interpret
Answer: B) Provide written instructions
Rationale: For clients with hearing impairment, providing written materials ensures they have a
reference for instructions. Facing the client, speaking clearly, and using visual aids are also helpful.
Question 15: A nurse is administering a subcutaneous injection. Which of the following needle lengths is
appropriate for a subcutaneous injection?
A) 1/4 inch
B) 3/8 inch
C) 1 1/2 inches
D) 2 inches
Answer: B) 3/8 inch (or 5/8 inch)
Rationale: Subcutaneous injections are given into the fatty tissue below the skin. Needle lengths for
subcutaneous injections range from 3/8 to 5/8 inch, depending on client size and site.
Question 16: A nurse is providing end-of-life care to a client. Which of the following interventions is
appropriate?
A) Withdraw all comfort measures
B) Encourage family to leave the room
C) Provide pain management and symptom control
D) Discontinue all medications
Answer: C) Provide pain management and symptom control
Rationale: End-of-life care focuses on comfort, dignity, and quality of life. Pain management, symptom
control, and emotional/spiritual support are priorities.
a Review of 220 Questions and Correct
Detailed Answers / Hesi Fundamentals
Practice Test (New!)
Section 1: Safe and Effective Care Environment - 45 Questions
Question 1: A nurse is preparing to administer medications to a client. Which of the following actions is
the priority before administering the medication?
A) Check the client's vital signs
B) Verify the client's identity using two identifiers
C) Review the medication's side effects
D) Assess the client's allergies
Answer: B) Verify the client's identity using two identifiers
Rationale: The priority action before any medication administration is verifying the client's identity using
two identifiers (e.g., name and date of birth) to ensure the right client receives the right medication. This
is a critical patient safety measure.
Question 2: A client is experiencing a seizure. Which of the following actions should the nurse take first?
A) Insert a padded tongue blade
B) Restrain the client's extremities
C) Move the client to a private room
D) Protect the client's head from injury
Answer: D) Protect the client's head from injury
Rationale: During a seizure, the priority is to protect the client from injury. Placing a hand or soft object
under the head prevents head trauma. Never insert anything into the mouth or restrain movements.
Question 3: A nurse is caring for a client who has a nasogastric tube. Which of the following actions is
appropriate to verify tube placement?
A) Aspirate gastric contents and check pH
B) Auscultate for air insufflation over the epigastric area
C) Observe the color of the aspirated fluid
D) Measure the length of the external tube
Answer: A) Aspirate gastric contents and check pH
Rationale: The most reliable method to verify NG tube placement is aspiration of gastric contents and pH
testing (pH should be ≤5). Auscultation (the "whoosh" test) is no longer considered reliable. X-ray is the
gold standard.
,Question 4: A nurse is preparing to discharge a client who is prescribed home oxygen therapy. Which of
the following instructions should the nurse include?
A) "Keep oxygen cylinders in a horizontal position"
B) "Apply petroleum-based ointment to nares"
C) "Post 'No Smoking' signs in your home"
D) "Increase oxygen flow during exercise"
Answer: C) "Post 'No Smoking' signs in your home"
Rationale: Oxygen is highly flammable. Clients and families must be educated about fire safety, including
posting "No Smoking" signs, avoiding open flames, and keeping oxygen away from heat sources.
Question 5: A nurse is performing a sterile dressing change. Which of the following actions maintains a
sterile field?
A) Placing the sterile drape with the shiny side down
B) Reaching over the sterile field to retrieve a dropped item
C) Opening the sterile package away from the body
D) Using sterile gloves that have been opened for 30 minutes
Answer: C) Opening the sterile package away from the body
Rationale: Opening the sterile package away from the body prevents contamination from the nurse's
clothing or body. The outer edge of the sterile field is also considered contaminated.
Question 6: A client is receiving a blood transfusion and develops sudden chills, fever, and flank pain.
The nurse should first:
A) Stop the transfusion
B) Slow the transfusion rate
C) Administer an antihistamine
D) Notify the provider
Answer: A) Stop the transfusion
Rationale: These symptoms indicate a possible hemolytic transfusion reaction. The nurse's priority is to
stop the transfusion immediately, disconnect the tubing, and maintain IV access with new tubing and
normal saline.
Question 7: A nurse is teaching a client about the use of a patient-controlled analgesia (PCA) pump.
Which of the following statements by the client indicates understanding?
A) "I will press the button every 15 minutes whether I have pain or not"
B) "My family can press the button if I am asleep"
C) "I should press the button when I feel pain"
D) "The pump will automatically deliver medication every hour"
Answer: C) "I should press the button when I feel pain"
Rationale: PCA pumps allow clients to self-administer pain medication when needed. The client should
press the button when pain is present. Only the client should press the button to prevent overdose.
Question 8: A client is placed in restraints. Which of the following actions is the nurse's priority?
A) Document the type of restraint used
B) Assess the client's vital signs
,C) Check the client's skin integrity and circulation every 2 hours
D) Obtain a provider's order within 24 hours
Answer: C) Check the client's skin integrity and circulation every 2 hours
Rationale: The priority is to monitor the client's safety and well-being. Skin integrity and circulation must
be assessed every 2 hours, and restraints should be removed for range of motion exercises.
Question 9: A nurse is assisting with a procedure that requires informed consent. Which of the following
clients is able to give informed consent?
A) A 17-year-old who is married
B) A 16-year-old who is emancipated
C) A client who is oriented and alert
D) A client who is under the influence of pain medication
Answer: C) A client who is oriented and alert
Rationale: Informed consent requires that the client be alert, oriented, and able to understand the risks,
benefits, and alternatives to the procedure. Emancipated minors may consent in some jurisdictions, but
the best answer is an alert, oriented adult client.
Question 10: A nurse is documenting client care. Which of the following is an appropriate
documentation entry?
A) "The client appears to be in pain"
B) "The client is faking symptoms"
C) "The client is confused and disoriented"
D) "The client reports chest pain rated 6/10"
Answer: D) "The client reports chest pain rated 6/10"
Rationale: Documentation should be objective, factual, and use direct quotes when possible. "Reports
chest pain rated 6/10" is objective and measurable. Opinions and judgments (appears, faking) are
inappropriate.
Question 11: A nurse is preparing to transfer a client from a bed to a chair. Which of the following
actions is most important for the nurse's safety?
A) Use the client's gait belt
B) Position the chair at a 45-degree angle
C) Place the bed in the lowest position
D) Assess the client's ability to bear weight
Answer: D) Assess the client's ability to bear weight
Rationale: Before any transfer, the nurse must assess the client's ability to bear weight and participate in
the transfer. This determines the type of transfer and equipment needed for safety.
Question 12: A client is prescribed a fall risk protocol. Which of the following interventions is
appropriate to include?
A) Keeping the bed in the highest position
B) Placing the call bell within reach
C) Using restraints at all times
D) Keeping the room lights dim
, Answer: B) Placing the call bell within reach
Rationale: For clients at risk for falls, the call bell should be within easy reach, the bed should be in the
lowest position, brakes locked, and nonskid socks should be worn. Restraints are a last resort.
Question 13: A nurse discovers a fire in a client's room. Which of the following actions should the nurse
take first?
A) Activate the fire alarm
B) Evacuate the client
C) Extinguish the fire
D) Close the door
Answer: B) Evacuate the client
Rationale: According to the RACE protocol (Rescue, Alarm, Contain, Extinguish), the nurse should first
rescue (evacuate) clients in immediate danger, then activate the alarm, contain the fire, and extinguish if
safe.
Question 14: A client with a hearing impairment has difficulty understanding discharge instructions.
Which of the following actions is most appropriate?
A) Speak loudly and slowly
B) Provide written instructions
C) Use hand gestures only
D) Ask a family member to interpret
Answer: B) Provide written instructions
Rationale: For clients with hearing impairment, providing written materials ensures they have a
reference for instructions. Facing the client, speaking clearly, and using visual aids are also helpful.
Question 15: A nurse is administering a subcutaneous injection. Which of the following needle lengths is
appropriate for a subcutaneous injection?
A) 1/4 inch
B) 3/8 inch
C) 1 1/2 inches
D) 2 inches
Answer: B) 3/8 inch (or 5/8 inch)
Rationale: Subcutaneous injections are given into the fatty tissue below the skin. Needle lengths for
subcutaneous injections range from 3/8 to 5/8 inch, depending on client size and site.
Question 16: A nurse is providing end-of-life care to a client. Which of the following interventions is
appropriate?
A) Withdraw all comfort measures
B) Encourage family to leave the room
C) Provide pain management and symptom control
D) Discontinue all medications
Answer: C) Provide pain management and symptom control
Rationale: End-of-life care focuses on comfort, dignity, and quality of life. Pain management, symptom
control, and emotional/spiritual support are priorities.
