HESI RN Fundamentals 2026–2027 Practice
Exam: Original Questions & Answers with
Detailed Rationales — Complete Exam
Prep Study Guide
Question 1
A nurse enters a client's room and finds the client lying on the floor. What should
the nurse do first?
A. Help the client back into bed
B. Assess the client for injury
C. Notify the healthcare provider
D. Complete an incident report
Answer: B. Assess the client for injury
Rationale: The nurse's first responsibility is to assess the client and determine
whether an injury occurred. The client should not be moved until injury,
particularly a possible spinal injury, has been evaluated.
Question 2
Which action is most effective for preventing healthcare-associated infections?
A. Wearing gloves for every client interaction
B. Performing hand hygiene appropriately
C. Wearing a surgical mask when entering every room
D. Administering prophylactic antibiotics
Answer: B. Performing hand hygiene appropriately
,Rationale: Hand hygiene is one of the most important measures for preventing
transmission of microorganisms between clients and healthcare workers.
Question 3
A nurse is preparing to administer an oral medication. Which identification method
is safest?
A. Ask the client to state the room number
B. Verify the client's name and date of birth against the identification band and
medication record
C. Ask another nurse to identify the client
D. Identify the client by diagnosis
Answer: B. Verify the client's name and date of birth against the identification
band and medication record
Rationale: Two appropriate client identifiers should be compared with the
medication administration record before medication administration. Room number
and diagnosis are not acceptable identifiers.
Question 4
A client reports dizziness when standing. Which intervention should the nurse
implement first?
A. Encourage rapid ambulation
B. Assist the client back to a safe sitting or lying position
C. Restrict oral fluids
D. Administer a prescribed analgesic
Answer: B. Assist the client back to a safe sitting or lying position
Rationale: Safety is the priority. Returning the client to a stable position helps
prevent a fall and allows further assessment of possible orthostatic hypotension.
,Question 5
Which finding requires the nurse's immediate attention?
A. Temperature of 37.1°C (98.8°F)
B. Respiratory rate of 8/min
C. Pulse of 78/min
D. Blood pressure of 118/72 mm Hg
Answer: B. Respiratory rate of 8/min
Rationale: A respiratory rate of 8/min indicates significant bradypnea and possible
respiratory depression. Airway and breathing take priority.
Question 6
A nurse is using the nursing process. Which activity represents the assessment
phase?
A. Establishing nursing diagnoses
B. Collecting subjective and objective data
C. Developing expected outcomes
D. Determining whether goals were achieved
Answer: B. Collecting subjective and objective data
Rationale: Assessment involves systematically collecting and validating
information about the client's health status.
Question 7
Which statement by a client demonstrates correct understanding of incentive
spirometer use?
A. "I will breathe out forcefully into the device."
B. "I will inhale slowly and deeply through the mouthpiece."
C. "I should use it only when I feel short of breath."
D. "I should lie completely flat while using it."
Answer: B. "I will inhale slowly and deeply through the mouthpiece."
, Rationale: Incentive spirometry promotes lung expansion by encouraging slow,
sustained deep inhalation.
Question 8
A nurse is caring for a client at risk for pressure injury. Which intervention is most
appropriate?
A. Massage reddened bony prominences
B. Reposition the client regularly
C. Keep the client's skin moist
D. Use a donut-shaped device under the sacrum
Answer: B. Reposition the client regularly
Rationale: Regular repositioning relieves prolonged pressure. Massaging reddened
areas can damage tissue, and donut devices can concentrate pressure around tissue.
Question 9
Which documentation entry is most appropriate?
A. "Client seems much better today."
B. "Client is difficult and uncooperative."
C. "Client ambulated 30 meters with one-person assistance."
D. "Client had a good day."
Answer: C. "Client ambulated 30 meters with one-person assistance."
Rationale: Documentation should be objective, specific, measurable, and based on
observable findings.
Question 10
A client tells the nurse, "I'm scared about my surgery." Which response is
therapeutic?
Exam: Original Questions & Answers with
Detailed Rationales — Complete Exam
Prep Study Guide
Question 1
A nurse enters a client's room and finds the client lying on the floor. What should
the nurse do first?
A. Help the client back into bed
B. Assess the client for injury
C. Notify the healthcare provider
D. Complete an incident report
Answer: B. Assess the client for injury
Rationale: The nurse's first responsibility is to assess the client and determine
whether an injury occurred. The client should not be moved until injury,
particularly a possible spinal injury, has been evaluated.
Question 2
Which action is most effective for preventing healthcare-associated infections?
A. Wearing gloves for every client interaction
B. Performing hand hygiene appropriately
C. Wearing a surgical mask when entering every room
D. Administering prophylactic antibiotics
Answer: B. Performing hand hygiene appropriately
,Rationale: Hand hygiene is one of the most important measures for preventing
transmission of microorganisms between clients and healthcare workers.
Question 3
A nurse is preparing to administer an oral medication. Which identification method
is safest?
A. Ask the client to state the room number
B. Verify the client's name and date of birth against the identification band and
medication record
C. Ask another nurse to identify the client
D. Identify the client by diagnosis
Answer: B. Verify the client's name and date of birth against the identification
band and medication record
Rationale: Two appropriate client identifiers should be compared with the
medication administration record before medication administration. Room number
and diagnosis are not acceptable identifiers.
Question 4
A client reports dizziness when standing. Which intervention should the nurse
implement first?
A. Encourage rapid ambulation
B. Assist the client back to a safe sitting or lying position
C. Restrict oral fluids
D. Administer a prescribed analgesic
Answer: B. Assist the client back to a safe sitting or lying position
Rationale: Safety is the priority. Returning the client to a stable position helps
prevent a fall and allows further assessment of possible orthostatic hypotension.
,Question 5
Which finding requires the nurse's immediate attention?
A. Temperature of 37.1°C (98.8°F)
B. Respiratory rate of 8/min
C. Pulse of 78/min
D. Blood pressure of 118/72 mm Hg
Answer: B. Respiratory rate of 8/min
Rationale: A respiratory rate of 8/min indicates significant bradypnea and possible
respiratory depression. Airway and breathing take priority.
Question 6
A nurse is using the nursing process. Which activity represents the assessment
phase?
A. Establishing nursing diagnoses
B. Collecting subjective and objective data
C. Developing expected outcomes
D. Determining whether goals were achieved
Answer: B. Collecting subjective and objective data
Rationale: Assessment involves systematically collecting and validating
information about the client's health status.
Question 7
Which statement by a client demonstrates correct understanding of incentive
spirometer use?
A. "I will breathe out forcefully into the device."
B. "I will inhale slowly and deeply through the mouthpiece."
C. "I should use it only when I feel short of breath."
D. "I should lie completely flat while using it."
Answer: B. "I will inhale slowly and deeply through the mouthpiece."
, Rationale: Incentive spirometry promotes lung expansion by encouraging slow,
sustained deep inhalation.
Question 8
A nurse is caring for a client at risk for pressure injury. Which intervention is most
appropriate?
A. Massage reddened bony prominences
B. Reposition the client regularly
C. Keep the client's skin moist
D. Use a donut-shaped device under the sacrum
Answer: B. Reposition the client regularly
Rationale: Regular repositioning relieves prolonged pressure. Massaging reddened
areas can damage tissue, and donut devices can concentrate pressure around tissue.
Question 9
Which documentation entry is most appropriate?
A. "Client seems much better today."
B. "Client is difficult and uncooperative."
C. "Client ambulated 30 meters with one-person assistance."
D. "Client had a good day."
Answer: C. "Client ambulated 30 meters with one-person assistance."
Rationale: Documentation should be objective, specific, measurable, and based on
observable findings.
Question 10
A client tells the nurse, "I'm scared about my surgery." Which response is
therapeutic?
