Nursing Fundamentals BSN 225
HESI(New 2026- 2027) Questions &
Answers with Rationale 100% Correct
Grade A - Nightingale
Question 1
A postoperative client attempts to get out of bed, and the spouse encourages the client to
walk because ambulation helps recovery. The client appears weak and unsteady. What should
the nurse do?
CORRECT ANSWER:
The nurse should help the client lie back down and then explain to the spouse the need for
ambulation to reduce potential postoperative complications.
RATIONALE:
The nurse's priority is client safety.
Although early ambulation is important after surgery to prevent complications such as:
• Deep vein thrombosis (DVT).
• Pneumonia.
• Constipation.
• Reduced mobility.
The client must first be assessed for:
• Strength.
• Balance.
• Ability to ambulate safely.
The nurse should prevent falls and educate the spouse that ambulation should occur only when
the client is stable and able to do so safely.
,Question 2
Which statement describes range-of-motion (ROM) exercises involving hinge joints?
CORRECT ANSWER:
Hinge joints allow flexion and extension movements. The humeroulnar joint at the elbow is
an example.
RATIONALE:
Hinge joints permit movement in one direction:
• Flexion: Bending a joint and decreasing the angle between bones.
• Extension: Straightening a joint and increasing the angle between bones.
Example:
• The elbow joint (humeroulnar joint) allows flexion and extension.
• The biceps muscle flexes the elbow.
• The triceps muscle extends the elbow.
Other examples of hinge joints include:
• Knee joint.
• Ankle joint.
Question 3
A client who is on a clear liquid diet has coffee on the tray. What should the nurse teach the
client?
CORRECT ANSWER:
Black coffee is considered a clear liquid, but milk or creamer should not be added.
RATIONALE:
A clear liquid diet includes fluids that are transparent and leave minimal residue.
Allowed:
, ✔ Water
✔ Clear broth
✔ Tea
✔ Black coffee
✔ Clear juices without pulp
Not allowed:
✘ Milk
✘ Cream
✘ Solid foods
Adding milk or creamer changes the diet from clear liquid to full liquid.
Question 4
A client has a Braden risk assessment score of 10. Which intervention should the nurse
implement?
CORRECT ANSWER:
Turn the client frequently to prevent pressure sores.
RATIONALE:
The Braden Scale measures a client's risk for developing pressure injuries.
• Scale range: 6–23
• Lower scores indicate greater risk.
A score of 10 indicates high risk.
Nursing interventions include:
• Frequent repositioning.
• Skin assessment.
• Pressure-relieving mattresses.
• Maintaining clean and dry skin.
Question 5
HESI(New 2026- 2027) Questions &
Answers with Rationale 100% Correct
Grade A - Nightingale
Question 1
A postoperative client attempts to get out of bed, and the spouse encourages the client to
walk because ambulation helps recovery. The client appears weak and unsteady. What should
the nurse do?
CORRECT ANSWER:
The nurse should help the client lie back down and then explain to the spouse the need for
ambulation to reduce potential postoperative complications.
RATIONALE:
The nurse's priority is client safety.
Although early ambulation is important after surgery to prevent complications such as:
• Deep vein thrombosis (DVT).
• Pneumonia.
• Constipation.
• Reduced mobility.
The client must first be assessed for:
• Strength.
• Balance.
• Ability to ambulate safely.
The nurse should prevent falls and educate the spouse that ambulation should occur only when
the client is stable and able to do so safely.
,Question 2
Which statement describes range-of-motion (ROM) exercises involving hinge joints?
CORRECT ANSWER:
Hinge joints allow flexion and extension movements. The humeroulnar joint at the elbow is
an example.
RATIONALE:
Hinge joints permit movement in one direction:
• Flexion: Bending a joint and decreasing the angle between bones.
• Extension: Straightening a joint and increasing the angle between bones.
Example:
• The elbow joint (humeroulnar joint) allows flexion and extension.
• The biceps muscle flexes the elbow.
• The triceps muscle extends the elbow.
Other examples of hinge joints include:
• Knee joint.
• Ankle joint.
Question 3
A client who is on a clear liquid diet has coffee on the tray. What should the nurse teach the
client?
CORRECT ANSWER:
Black coffee is considered a clear liquid, but milk or creamer should not be added.
RATIONALE:
A clear liquid diet includes fluids that are transparent and leave minimal residue.
Allowed:
, ✔ Water
✔ Clear broth
✔ Tea
✔ Black coffee
✔ Clear juices without pulp
Not allowed:
✘ Milk
✘ Cream
✘ Solid foods
Adding milk or creamer changes the diet from clear liquid to full liquid.
Question 4
A client has a Braden risk assessment score of 10. Which intervention should the nurse
implement?
CORRECT ANSWER:
Turn the client frequently to prevent pressure sores.
RATIONALE:
The Braden Scale measures a client's risk for developing pressure injuries.
• Scale range: 6–23
• Lower scores indicate greater risk.
A score of 10 indicates high risk.
Nursing interventions include:
• Frequent repositioning.
• Skin assessment.
• Pressure-relieving mattresses.
• Maintaining clean and dry skin.
Question 5
