HESI-RN FUNDAMENTAL /RN HESI FUNDAMENTAL LATEST
VERSION B 2026-2027 ALL 130 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+.
QUESTION
The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
CORRECT ANS: B. Use of careful handwashing technique
Expert Rationale
Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. It is a fundamental and proven infection
control practice that breaks the chain of infection by removing pathogens from the
hands. Option A reverses the hypovolemia that initially accompanies burn trauma but is
not related to decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of
infection, but they are not as universally effective as handwashing. Handwashing is the
gold standard for infection prevention.
DIF: Cognitive Level: Understand (Comprehension) TOP: Fundamentals MSC: N/A
QUESTION
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
CORRECT ANS: B. Check for kinks in the tubing and raise the IV pole.
Expert Rationale
The nurse should first check the tubing and height of the bag on the IV pole, which are
common factors that may slow the rate. Gravity infusion rates are influenced by the
height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity,
client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow
the rate and often responds to warmth over the vessel, but the nurse should first adjust
,the IV pole height. The nurse may need to adjust the stabilizing tape on a positional
needle or flush the venous access with normal saline, but less invasive actions should be
implemented first.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
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?
CORRECT ANS: A. Perform range-of-motion exercises to prevent contractures.
Expert 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. Decreasing fluid intake can lead to dehydration and
urinary tract issues, massaging legs can dislodge thrombi, and turning only once per
shift is insufficient to prevent pressure ulcers.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
The nurse administered 10 mg of diazepam to the preoperative client. What steps will
the nurse take next? (Select all that apply.)
CORRECT ANS: 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.
Expert Rationale
Diazepam is a common preoperative medication with sedative effects. The client should
not get out of bed, even with assistance, due to the risk of falls. Placing the call bell
within reach and raising the side rails are standard safety measures. Close observation
by placing the client next to the nurse's station is not necessary. Assisting the client to
the bathroom is contraindicated due to the sedative effect.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
,QUESTION
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?
CORRECT ANS: B. Right cephalic vein
Expert 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.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
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?
CORRECT ANS: D. Contact the health care provider to renew the prescription for the
medication.
Expert Rationale
Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the health care provider if the antihypertensive medication is not
included in the postoperative prescriptions. The pharmacist does not prescribe
medications or renew prescriptions. The nurse must have a current prescription before
administering any medications. Withholding the medication without a prescription is
also unsafe.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
, QUESTION
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. Which action should the nurse take
next?
CORRECT ANS: A. Record the amount on the client's fluid output record.
Expert Rationale
The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output, but no additional action is needed. Normal urine output
is at least 30 mL/hour, so 350 mL in 4 hours is adequate. There is no need to encourage
fluid intake, notify the healthcare provider, or palpate the bladder.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
The client states to the nurse, "This medication makes my mouth so dry." What are the
nurse's suggestions to quench the client's thirst? (Select all that apply.)
CORRECT ANS: B. Infuse your water with fresh citrus fruits to quench your thirst. C.
Freeze strawberries and water together in popsicle mold. E. Keep a few pieces of hard
candy with you to suck on.
Expert Rationale
Sodas do not tend to be thirst quenching because of the amount of sugar in them that
draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming
frozen liquids. Hard candy can produce moisture in the mouth. Adding ginger ale to
juice adds sugar and is not as effective. The client should avoid sugary drinks to stay
hydrated.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
The nurse notes in the client's plan of care altered sleep patterns related to nocturia.
Which nursing actions are important for the nurse to provide? (Select all that apply.)
VERSION B 2026-2027 ALL 130 QUESTIONS AND CORRECT
DETAILED ANSWERS WITH RATIONALES (VERIFIED ANSWERS)
|ALREADY GRADED A+.
QUESTION
The nurse identifies a potential for infection in a client with partial-thickness (second-
degree) and full-thickness (third-degree) burns. What action has the highest priority in
decreasing the client's risk of infection?
CORRECT ANS: B. Use of careful handwashing technique
Expert Rationale
Careful handwashing technique is the single most effective intervention for the
prevention of contamination to all clients. It is a fundamental and proven infection
control practice that breaks the chain of infection by removing pathogens from the
hands. Option A reverses the hypovolemia that initially accompanies burn trauma but is
not related to decreasing the proliferation of infective organisms. Options C and D are
recommended by various burn centers as possible ways to reduce the chance of
infection, but they are not as universally effective as handwashing. Handwashing is the
gold standard for infection prevention.
DIF: Cognitive Level: Understand (Comprehension) TOP: Fundamentals MSC: N/A
QUESTION
The nurse assesses a 2-year-old who is admitted for dehydration and finds that the
peripheral IV rate by gravity has slowed, even though the venous access site is healthy.
What should the nurse do next?
CORRECT ANS: B. Check for kinks in the tubing and raise the IV pole.
Expert Rationale
The nurse should first check the tubing and height of the bag on the IV pole, which are
common factors that may slow the rate. Gravity infusion rates are influenced by the
height of the bag, tubing clamp closure or kinks, needle size or position, fluid viscosity,
client blood pressure (crying in the pediatric client), and infiltration. Venospasm can slow
the rate and often responds to warmth over the vessel, but the nurse should first adjust
,the IV pole height. The nurse may need to adjust the stabilizing tape on a positional
needle or flush the venous access with normal saline, but less invasive actions should be
implemented first.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
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?
CORRECT ANS: A. Perform range-of-motion exercises to prevent contractures.
Expert 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. Decreasing fluid intake can lead to dehydration and
urinary tract issues, massaging legs can dislodge thrombi, and turning only once per
shift is insufficient to prevent pressure ulcers.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
The nurse administered 10 mg of diazepam to the preoperative client. What steps will
the nurse take next? (Select all that apply.)
CORRECT ANS: 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.
Expert Rationale
Diazepam is a common preoperative medication with sedative effects. The client should
not get out of bed, even with assistance, due to the risk of falls. Placing the call bell
within reach and raising the side rails are standard safety measures. Close observation
by placing the client next to the nurse's station is not necessary. Assisting the client to
the bathroom is contraindicated due to the sedative effect.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
,QUESTION
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?
CORRECT ANS: B. Right cephalic vein
Expert 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.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
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?
CORRECT ANS: D. Contact the health care provider to renew the prescription for the
medication.
Expert Rationale
Medications prescribed preoperatively must be renewed postoperatively, so the nurse
should contact the health care provider if the antihypertensive medication is not
included in the postoperative prescriptions. The pharmacist does not prescribe
medications or renew prescriptions. The nurse must have a current prescription before
administering any medications. Withholding the medication without a prescription is
also unsafe.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
, QUESTION
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that
this is the first time the client has voided in 4 hours. Which action should the nurse take
next?
CORRECT ANS: A. Record the amount on the client's fluid output record.
Expert Rationale
The amount and appearance of the client's urine output is within normal limits, so the
nurse should record the output, but no additional action is needed. Normal urine output
is at least 30 mL/hour, so 350 mL in 4 hours is adequate. There is no need to encourage
fluid intake, notify the healthcare provider, or palpate the bladder.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
The client states to the nurse, "This medication makes my mouth so dry." What are the
nurse's suggestions to quench the client's thirst? (Select all that apply.)
CORRECT ANS: B. Infuse your water with fresh citrus fruits to quench your thirst. C.
Freeze strawberries and water together in popsicle mold. E. Keep a few pieces of hard
candy with you to suck on.
Expert Rationale
Sodas do not tend to be thirst quenching because of the amount of sugar in them that
draws fluid into the GI system. Citrus infused water quenches thirst, as does consuming
frozen liquids. Hard candy can produce moisture in the mouth. Adding ginger ale to
juice adds sugar and is not as effective. The client should avoid sugary drinks to stay
hydrated.
DIF: Cognitive Level: Apply (Application) TOP: Fundamentals MSC: N/A
QUESTION
The nurse notes in the client's plan of care altered sleep patterns related to nocturia.
Which nursing actions are important for the nurse to provide? (Select all that apply.)
