HESI RN FUNDAMENTALS 2026 FINAL EXAM ALL
QUESTIONS AND ANSWERS SURE A+
✔✔The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in this
instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - ✔✔A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures
around joints. Options B, C, and D are all potentially harmful practices that place the
immobile client at risk of complications.
✔✔The nurse administered 10 mg of diazepam to the preoperative client. What steps
will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
,Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ✔✔B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by
placing the client close to the nurse's station is not necessary. The medication has a
sedative effect and the client should not get out of bed, even with assistance. The
remaining selections are correct.
✔✔A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help
me to die." Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. - ✔✔B
Rationale: The nurse should first assess the client's feelings about death and determine
the extent to which this statement expresses the client's true feelings. The client may
need additional pain management, but further assessment is needed before
implementing option A. Options C and D are both premature interventions and should
not be implemented until further assessment is obtained.
✔✔A nurse stops at a motor vehicle collision site to render aid until the emergency
personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later
the client has to have the leg amputated and sues the nurse for malpractice. Which
statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could
lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the
Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach, causation,
and damages) can be proved. - ✔✔C
Rationale: The Good Samaritan Act protects health care professionals who practice in
good faith and provide reasonable care from malpractice claims, regardless of the client
outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by
,the Good Samaritan Act. The state Board of Nursing has no reason to revoke a
registered nurse's license unless there was evidence that actions taken in the
emergency were not done in good faith or that reasonable care was not provided. All
four elements of malpractice were not shown.
✔✔An older client who had abdominal surgery 3 days earlier was given a barbiturate for
sleep and is now requesting to go to the bathroom. What is the priority nursing action for
this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ✔✔A
Rationale: Barbiturates cause central nervous system (CNS) depression, and
individuals taking these medications are at greater risk for falls. The nurse should assist
the client to the bathroom. A bedpan is not necessary as long as safety is ensured.
Whether the client needs to void or have a bowel movement, option C is irrelevant in
terms of meeting this client's safety needs. There is no indication that this client cannot
voice her or his needs, so assessment of the bladder is not needed.
✔✔The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ✔✔D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is a
problem that may develop from having an indwelling catheter. Option B may or may not
be true for the client. Option C is not affected by an indwelling catheter.
✔✔When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
, Ask the parents why the child is not circumcised. - ✔✔C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all
areas that could harbor bacteria. The child's cognitive development may not be at the
level at which option A would be effective. Perineal care needs to be provided daily
regardless of the client's age. Option D is not indicated and may be perceived as
intrusive.
✔✔A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - ✔✔B
Rationale: Caring for a close friend can violate boundaries for nurses and should be
avoided when possible (B). If the assignment is unavoidable (there are no other nurses
to care for the client) then C, A, and D should be addressed.
✔✔The nurse selects the best site for insertion of an IV catheter in the client's right arm.
Which documentation should the nurse use to identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - ✔✔B
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of
the vein that is accessed, which should be included in the documentation. The basilic
vein of the arm is used for IV access, not the brachial vein, which is too deep to be
accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible,
they are fragile and using them would be painful, so they are not recommended for IV
access. Option D is not specific enough for documenting the location of the IV access.
✔✔The nurse transcribes the postoperative prescriptions for a client who returns to the
unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
QUESTIONS AND ANSWERS SURE A+
✔✔The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on
ways to prevent complications of immobility. Which action should be included in this
instruction?
A.
Perform range-of-motion exercises to prevent contractures.
B.
Decrease the client's fluid intake to prevent diarrhea.
C.
Massage the client's legs to reduce embolism occurrence.
D.
Turn the client from side to back every shift. - ✔✔A
Rationale: Performing range-of-motion exercises is beneficial in reducing contractures
around joints. Options B, C, and D are all potentially harmful practices that place the
immobile client at risk of complications.
✔✔The nurse administered 10 mg of diazepam to the preoperative client. What steps
will the nurse take next? (Select all that apply.)
A.
Place the client in the bed next to the nurse's station.
B.
,Instruct the client not to get out of bed.
C.
Place the call bell within the client's reach.
D.
Place the side rails up, according to institutional policy.
E.
Assist the client to the bathroom - ✔✔B, C, D
Rationale: Diazepam is a common preoperative medication. Close observation by
placing the client close to the nurse's station is not necessary. The medication has a
sedative effect and the client should not get out of bed, even with assistance. The
remaining selections are correct.
✔✔A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help
me to die." Which is the best response for the nurse to provide?
A.
Administer the prescribed maximum dose of pain medication.
B.
Talk with the client about thoughts and feelings about death.
C.
Collaborate with the health care provider about initiating antidepressant therapy.
D.
Refer the client to the ethics committee of her local health care facility. - ✔✔B
Rationale: The nurse should first assess the client's feelings about death and determine
the extent to which this statement expresses the client's true feelings. The client may
need additional pain management, but further assessment is needed before
implementing option A. Options C and D are both premature interventions and should
not be implemented until further assessment is obtained.
✔✔A nurse stops at a motor vehicle collision site to render aid until the emergency
personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later
the client has to have the leg amputated and sues the nurse for malpractice. Which
statement reflects the likely outcome for the nurse?
A.
The Patient's Bill of Rights protects clients from malicious intents, so the nurse could
lose the case.
B.
The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
C.
There will be no judgment against the nurse, whose actions are protected under the
Good Samaritan Act.
D.
The client will win because the four elements of negligence (duty, breach, causation,
and damages) can be proved. - ✔✔C
Rationale: The Good Samaritan Act protects health care professionals who practice in
good faith and provide reasonable care from malpractice claims, regardless of the client
outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by
,the Good Samaritan Act. The state Board of Nursing has no reason to revoke a
registered nurse's license unless there was evidence that actions taken in the
emergency were not done in good faith or that reasonable care was not provided. All
four elements of malpractice were not shown.
✔✔An older client who had abdominal surgery 3 days earlier was given a barbiturate for
sleep and is now requesting to go to the bathroom. What is the priority nursing action for
this client?
A.
Assist the client to walk to the bathroom and do not leave the client alone.
B.
Request that the UAP assist the client onto a bedpan.
C.
Ask if the client needs to have a bowel movement or void.
D.
Assess the client's bladder to determine if the client needs to urinate. - ✔✔A
Rationale: Barbiturates cause central nervous system (CNS) depression, and
individuals taking these medications are at greater risk for falls. The nurse should assist
the client to the bathroom. A bedpan is not necessary as long as safety is ensured.
Whether the client needs to void or have a bowel movement, option C is irrelevant in
terms of meeting this client's safety needs. There is no indication that this client cannot
voice her or his needs, so assessment of the bladder is not needed.
✔✔The nurse is planning care for a client with an indwelling urinary catheter. Which
nursing action has the highest priority?
A.
Assist the client with daily cleansing.
B.
Tell the client that incontinence happens with aging.
C.
Offer 200 mL of fluid every 2 hours while awake.
D.
Take the client's temperature every 4 hours. - ✔✔D
Rationale: Indwelling urinary catheters are a major source of infection. Option A is a
problem that may develop from having an indwelling catheter. Option B may or may not
be true for the client. Option C is not affected by an indwelling catheter.
✔✔When bathing an uncircumcised boy older than 3 years, which action should the
nurse take?
A.
Remind the child to clean his genital area.
B.
Defer perineal care because of the child's age.
C.
Retract the foreskin gently to cleanse the penis.
D.
, Ask the parents why the child is not circumcised. - ✔✔C
Rationale: The foreskin (prepuce) of the penis should be gently retracted to cleanse all
areas that could harbor bacteria. The child's cognitive development may not be at the
level at which option A would be effective. Perineal care needs to be provided daily
regardless of the client's age. Option D is not indicated and may be perceived as
intrusive.
✔✔A nurse is assigned to care for a close friend in the hospital setting. Which action
should the nurse take first when given the assignment?
A.
Notify the friend that all medical information will be kept confidential.
B.
Explain the relationship to the charge nurse and ask for reassignment.
C.
Approach the client and ask if the assignment is uncomfortable.
D.
Accept the assignment but protect the client's confidentiality. - ✔✔B
Rationale: Caring for a close friend can violate boundaries for nurses and should be
avoided when possible (B). If the assignment is unavoidable (there are no other nurses
to care for the client) then C, A, and D should be addressed.
✔✔The nurse selects the best site for insertion of an IV catheter in the client's right arm.
Which documentation should the nurse use to identify placement of the IV access?
A.
Left brachial vein
B.
Right cephalic vein
C.
Dorsal side of the right wrist
D.
Right upper extremity - ✔✔B
Rationale: The cephalic vein is large and superficial and identifies the anatomic name of
the vein that is accessed, which should be included in the documentation. The basilic
vein of the arm is used for IV access, not the brachial vein, which is too deep to be
accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible,
they are fragile and using them would be painful, so they are not recommended for IV
access. Option D is not specific enough for documenting the location of the IV access.
✔✔The nurse transcribes the postoperative prescriptions for a client who returns to the
unit following surgery and notes that an antihypertensive medication that was
prescribed preoperatively is not listed. Which action should the nurse take?
A.
Consult with the pharmacist about the need to continue the medication.
B.
Administer the antihypertensive medication as prescribed preoperatively.
C.
