Comprehensive review covering Fundamental Concepts, Med-Surg, Maternity, Pediatrics,
Psych/Mental Health, Pharmacology/Dosage Calculations, Nutrition, and Ethics/Legal Issues. Each
question includes multiple-choice options, correct answers, and detailed rationales with clinical
reasoning. Designed for HESI and NCLEX success. Focuses on prioritization, safety, delegation,
therapeutic communication, and evidence-based practice. Ideal for nursing students seeking to
strengthen critical thinking and pass the HESI exit exam with confidence.
SECTION 1: FUNDAMENTAL NURSING CONCEPTS
1. The nurse is caring for a client who is receiving continuous oxygen via nasal cannula at 2 L/min.
Which action is most important for the nurse to implement?
1. Apply water-soluble lubricant to the client's nares
2. Check the oxygen saturation level every 4 hours
3. Ensure the oxygen tubing is connected properly
4. Post a "No Smoking" sign on the client's door
Correct Answer: 1
Rationale: Applying water-soluble lubricant to the client's nares is most important to prevent
drying and cracking of the nasal mucosa, which can lead to discomfort and bleeding. While
options 2, 3, and 4 are all important safety measures, preventing skin breakdown and mucosal
damage is a priority for client comfort and safety.
2. A client is receiving a blood transfusion. Which assessment finding requires immediate
intervention by the nurse?
1. Temperature increase from 98.6°F to 99.2°F (37°C to 37.3°C)
2. Complaints of mild itching at the IV site
3. Blood pressure 110/70 mm Hg, pulse 88 beats/min
4. Client reports feeling anxious and has chills
Correct Answer: 4
Rationale: Chills and anxiety are early signs of a transfusion reaction, which can rapidly
progress to a hemolytic reaction. This requires immediate discontinuation of the transfusion and
notification of the provider. Option 1 shows a mild temperature elevation that should be
,monitored but doesn't require immediate intervention. Option 2 is a localized reaction. Option 3
shows stable vital signs.
3. The nurse is calculating the intake and output for a client over 8 hours. The client received 1000
mL of IV fluids, 250 mL of blood, and 150 mL of oral fluids. Output was 900 mL of urine, 100 mL
of drainage from a surgical drain, and 50 mL of emesis. What is the client's fluid balance?
1. +250 mL
2. +350 mL
3. +450 mL
4. +550 mL
Correct Answer: 2
Rationale: Total intake = 1000 + 250 + 150 = 1400 mL. Total output = 900 + 100 + 50 =
1050 mL. Fluid balance = Intake - Output = 1400 - 1050 = +350 mL (positive balance). A
positive balance indicates the client is retaining fluid.
4. A nurse stops at a motor vehicle collision site to render aid until 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 is the most likely outcome of this
lawsuit?
1. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the
case.
2. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
3. There will be no judgment against the nurse, whose actions were protected under the Good
Samaritan Act.
4. The client will win because the four elements of negligence (duty, breach, causation, and
damages) can be proved.
Correct Answer: 3
Rationale: The Good Samaritan Act specifically protects health care professionals who provide
care in good faith and with reasonable skill at emergency scenes from malpractice claims,
regardless of the client outcome. The nurse was acting in an emergency capacity without
expectation of compensation. While the Patient's Bill of Rights protects clients, this nurse is
protected by the Good Samaritan Act. All four elements of malpractice were not demonstrated
because duty and breach of duty could not be established in this Good Samaritan context.
5. When the health care provider diagnoses metastatic cancer and recommends a gastrostomy
for an older female client in stable condition, the son tells the nurse that his mother must not be
told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal
principle is the court most likely to uphold regarding this client's right to informed consent?
1. The family can provide the consent required in this situation because the older adult is in no
condition to make such decisions.
2. Because the client is mentally incompetent, the son has the right to waive informed consent for
her.
, 3. The court will allow the health care provider to make the decision to withhold informed
consent under therapeutic privilege.
4. If informed consent is withheld from a client, health care providers could be found guilty of
negligence.
Correct Answer: 4
Rationale: Health care providers may be found guilty of negligence, specifically assault and
battery, if they carry out a treatment without the client's informed consent. The client's condition is
stable, so option 1 is not a valid rationale. Advanced age does not automatically authorize the
son to make all decisions for his mother, and there is no evidence that the client is mentally
incompetent. Although option 3 may have been upheld in the past when paternalistic medical
practice was common, today's courts are unlikely to accept it.
6. The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most
important for the nurse to implement?
1. Stay with the client while the client is standing.
2. Record the findings on the graphic sheet in the chart.
3. Keep the blood pressure cuff on the same arm.
4. Record changes in the client's pulse rate.
Correct Answer: 1
Rationale: Although all these measures are important for obtaining accurate orthostatic blood
pressure readings, staying with the client while standing is most important because it ensures client
safety. Clients can become dizzy or syncopal during position changes, leading to falls and injury.
Option 2 is necessary but does not have the priority of option 1. Options 3 and 4 are important
measures to ensure accuracy of the recording but are of less importance than providing client
safety.
7. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and
states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which
intervention is best for the nurse to implement?
1. Encourage the client to use a nicotine patch.
2. Reassure the client that it is almost time for another break.
3. Have the client leave the unit with another staff member.
4. Review the schedule of outdoor breaks with the client.
Correct Answer: 4
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide
concrete, factual information about the schedule. This validates the client's feelings while providing
clear expectations. Option 1 is contraindicated if the client wants to continue smoking. Option 2 is
insufficient and may be perceived as dismissive, which does not encourage a trusting therapeutic
relationship. Option 3 is preferential treatment for this client only and is inconsistent with unit rules
regarding supervised smoking breaks.
8. Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
, 1. White blood cell count
2. Albumin
3. Calcium
4. Sodium
Correct Answer: 4
Rationale: Sodium is the most critical laboratory value to monitor because NG tube suction
removes gastric secretions that contain significant amounts of sodium and potassium. Prolonged
suction can lead to hyponatremia and metabolic alkalosis. While albumin, calcium, and WBC
count are important, they are not the most immediate concern for a client with NG suction.
9. A client with heart failure is prescribed furosemide (Lasix) 40 mg IV push. Which assessment
finding indicates that the medication is having the desired therapeutic effect?
1. Blood pressure decreases from 150/90 to 130/80 mm Hg
2. Heart rate increases from 72 to 88 beats per minute
3. Urine output increases from 30 mL/hr to 80 mL/hr
4. Respiratory rate decreases from 24 to 18 breaths per minute
Correct Answer: 3
Rationale: Furosemide is a loop diuretic used to reduce fluid volume overload in heart failure.
The desired therapeutic effect is increased urine output to remove excess fluid. While blood
pressure may decrease and respiratory rate may improve as fluid is removed, increased urine
output is the most direct indicator of medication effectiveness. Option 4 indicates improvement but
is a secondary effect.
10. The nurse is preparing to administer an enteral feeding through a nasogastric tube. Which
action should the nurse take first?
1. Flush the tube with 30 mL of sterile water
2. Check the residual volume
3. Elevate the head of the bed to 30-45 degrees
4. Verify tube placement by checking the pH of aspirate
Correct Answer: 4
Rationale: Verifying proper tube placement is the priority before any enteral feeding to
prevent aspiration and ensure the tube is in the stomach. Checking pH of aspirate (should be ≤ 5)
provides verification of placement. While elevating the head of the bed, checking residuals, and
flushing are all important steps, they should follow placement verification.
11. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
1. Tell the client that the blood pressure is high and that the reading needs to be verified by
another nurse.
2. Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication.
3. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm
comfort.
Psych/Mental Health, Pharmacology/Dosage Calculations, Nutrition, and Ethics/Legal Issues. Each
question includes multiple-choice options, correct answers, and detailed rationales with clinical
reasoning. Designed for HESI and NCLEX success. Focuses on prioritization, safety, delegation,
therapeutic communication, and evidence-based practice. Ideal for nursing students seeking to
strengthen critical thinking and pass the HESI exit exam with confidence.
SECTION 1: FUNDAMENTAL NURSING CONCEPTS
1. The nurse is caring for a client who is receiving continuous oxygen via nasal cannula at 2 L/min.
Which action is most important for the nurse to implement?
1. Apply water-soluble lubricant to the client's nares
2. Check the oxygen saturation level every 4 hours
3. Ensure the oxygen tubing is connected properly
4. Post a "No Smoking" sign on the client's door
Correct Answer: 1
Rationale: Applying water-soluble lubricant to the client's nares is most important to prevent
drying and cracking of the nasal mucosa, which can lead to discomfort and bleeding. While
options 2, 3, and 4 are all important safety measures, preventing skin breakdown and mucosal
damage is a priority for client comfort and safety.
2. A client is receiving a blood transfusion. Which assessment finding requires immediate
intervention by the nurse?
1. Temperature increase from 98.6°F to 99.2°F (37°C to 37.3°C)
2. Complaints of mild itching at the IV site
3. Blood pressure 110/70 mm Hg, pulse 88 beats/min
4. Client reports feeling anxious and has chills
Correct Answer: 4
Rationale: Chills and anxiety are early signs of a transfusion reaction, which can rapidly
progress to a hemolytic reaction. This requires immediate discontinuation of the transfusion and
notification of the provider. Option 1 shows a mild temperature elevation that should be
,monitored but doesn't require immediate intervention. Option 2 is a localized reaction. Option 3
shows stable vital signs.
3. The nurse is calculating the intake and output for a client over 8 hours. The client received 1000
mL of IV fluids, 250 mL of blood, and 150 mL of oral fluids. Output was 900 mL of urine, 100 mL
of drainage from a surgical drain, and 50 mL of emesis. What is the client's fluid balance?
1. +250 mL
2. +350 mL
3. +450 mL
4. +550 mL
Correct Answer: 2
Rationale: Total intake = 1000 + 250 + 150 = 1400 mL. Total output = 900 + 100 + 50 =
1050 mL. Fluid balance = Intake - Output = 1400 - 1050 = +350 mL (positive balance). A
positive balance indicates the client is retaining fluid.
4. A nurse stops at a motor vehicle collision site to render aid until 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 is the most likely outcome of this
lawsuit?
1. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the
case.
2. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked.
3. There will be no judgment against the nurse, whose actions were protected under the Good
Samaritan Act.
4. The client will win because the four elements of negligence (duty, breach, causation, and
damages) can be proved.
Correct Answer: 3
Rationale: The Good Samaritan Act specifically protects health care professionals who provide
care in good faith and with reasonable skill at emergency scenes from malpractice claims,
regardless of the client outcome. The nurse was acting in an emergency capacity without
expectation of compensation. While the Patient's Bill of Rights protects clients, this nurse is
protected by the Good Samaritan Act. All four elements of malpractice were not demonstrated
because duty and breach of duty could not be established in this Good Samaritan context.
5. When the health care provider diagnoses metastatic cancer and recommends a gastrostomy
for an older female client in stable condition, the son tells the nurse that his mother must not be
told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal
principle is the court most likely to uphold regarding this client's right to informed consent?
1. The family can provide the consent required in this situation because the older adult is in no
condition to make such decisions.
2. Because the client is mentally incompetent, the son has the right to waive informed consent for
her.
, 3. The court will allow the health care provider to make the decision to withhold informed
consent under therapeutic privilege.
4. If informed consent is withheld from a client, health care providers could be found guilty of
negligence.
Correct Answer: 4
Rationale: Health care providers may be found guilty of negligence, specifically assault and
battery, if they carry out a treatment without the client's informed consent. The client's condition is
stable, so option 1 is not a valid rationale. Advanced age does not automatically authorize the
son to make all decisions for his mother, and there is no evidence that the client is mentally
incompetent. Although option 3 may have been upheld in the past when paternalistic medical
practice was common, today's courts are unlikely to accept it.
6. The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most
important for the nurse to implement?
1. Stay with the client while the client is standing.
2. Record the findings on the graphic sheet in the chart.
3. Keep the blood pressure cuff on the same arm.
4. Record changes in the client's pulse rate.
Correct Answer: 1
Rationale: Although all these measures are important for obtaining accurate orthostatic blood
pressure readings, staying with the client while standing is most important because it ensures client
safety. Clients can become dizzy or syncopal during position changes, leading to falls and injury.
Option 2 is necessary but does not have the priority of option 1. Options 3 and 4 are important
measures to ensure accuracy of the recording but are of less importance than providing client
safety.
7. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and
states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which
intervention is best for the nurse to implement?
1. Encourage the client to use a nicotine patch.
2. Reassure the client that it is almost time for another break.
3. Have the client leave the unit with another staff member.
4. Review the schedule of outdoor breaks with the client.
Correct Answer: 4
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide
concrete, factual information about the schedule. This validates the client's feelings while providing
clear expectations. Option 1 is contraindicated if the client wants to continue smoking. Option 2 is
insufficient and may be perceived as dismissive, which does not encourage a trusting therapeutic
relationship. Option 3 is preferential treatment for this client only and is inconsistent with unit rules
regarding supervised smoking breaks.
8. Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
, 1. White blood cell count
2. Albumin
3. Calcium
4. Sodium
Correct Answer: 4
Rationale: Sodium is the most critical laboratory value to monitor because NG tube suction
removes gastric secretions that contain significant amounts of sodium and potassium. Prolonged
suction can lead to hyponatremia and metabolic alkalosis. While albumin, calcium, and WBC
count are important, they are not the most immediate concern for a client with NG suction.
9. A client with heart failure is prescribed furosemide (Lasix) 40 mg IV push. Which assessment
finding indicates that the medication is having the desired therapeutic effect?
1. Blood pressure decreases from 150/90 to 130/80 mm Hg
2. Heart rate increases from 72 to 88 beats per minute
3. Urine output increases from 30 mL/hr to 80 mL/hr
4. Respiratory rate decreases from 24 to 18 breaths per minute
Correct Answer: 3
Rationale: Furosemide is a loop diuretic used to reduce fluid volume overload in heart failure.
The desired therapeutic effect is increased urine output to remove excess fluid. While blood
pressure may decrease and respiratory rate may improve as fluid is removed, increased urine
output is the most direct indicator of medication effectiveness. Option 4 indicates improvement but
is a secondary effect.
10. The nurse is preparing to administer an enteral feeding through a nasogastric tube. Which
action should the nurse take first?
1. Flush the tube with 30 mL of sterile water
2. Check the residual volume
3. Elevate the head of the bed to 30-45 degrees
4. Verify tube placement by checking the pH of aspirate
Correct Answer: 4
Rationale: Verifying proper tube placement is the priority before any enteral feeding to
prevent aspiration and ensure the tube is in the stomach. Checking pH of aspirate (should be ≤ 5)
provides verification of placement. While elevating the head of the bed, checking residuals, and
flushing are all important steps, they should follow placement verification.
11. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
1. Tell the client that the blood pressure is high and that the reading needs to be verified by
another nurse.
2. Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication.
3. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm
comfort.
