[HESI Fundamentals] COMPLETE EXAM QUESTIONS AND
VERIFIED ANSWERS | 2026–2027 LATEST UPDATE |
GUARANTEED PASS | DETAILED RATIONALES | FULL STUDY
GUIDE | EXAM PREP | PRACTICE TEST | CERTIFICATION
PREPARATION
Section One: Questions 1–100
1. A nurse is preparing to administer an enteral feeding to a client via a nasogastric (NG) tube.
Which action should the nurse take first to ensure safe administration?
A. Flush the tube with 30 mL of warm water.
B. Verify the placement of the tube by measuring the pH of the gastric aspirate.
C. Place the client in a supine position.
D. Check the residual volume to assess for delayed gastric emptying.
Correct Answer: B. Verify the placement of the tube by measuring the pH of the gastric aspirate.
Rationale: The priority action before any enteral feeding is to confirm the correct placement of the
tube to prevent accidental administration into the lungs. Measuring the pH of gastric aspirate
(typically 4 or less) is a reliable method to confirm gastric placement. Flushing and checking residual
are important but should occur after placement is verified. The client should be positioned in a semi-
Fowler's or high-Fowler's position (not supine) to reduce the risk of aspiration.
2. A client with a new colostomy is being discharged. Which statement by the client indicates a
correct understanding of dietary management?
A. "I should avoid all high-fiber foods to prevent blockage."
B. "I can eat any food as long as I chew it thoroughly."
C. "I should increase my intake of foods that cause gas, like beans and broccoli."
D. "I will need to take a daily laxative to ensure regular bowel movements."
Correct Answer: B. "I can eat any food as long as I chew it thoroughly."
Rationale: Clients with a new colostomy are often advised that they can return to a normal diet, but
they must chew food thoroughly to prevent blockage. While some foods may cause gas or odor, they
are not strictly prohibited. A high-fiber diet is not entirely avoided; it is introduced gradually.
Laxatives are not typically required and could cause complications.
3. A nurse is assessing a client's pain level. The client reports a "4" on a 0-10 pain scale but is
smiling and watching television. What is the nurse's best initial action?
A. Administer the prescribed analgesic immediately.
B. Document the discrepancy and re-evaluate in an hour.
C. Ask the client to describe the pain in more detail.
D. Use a different pain scale to validate the finding.
Correct Answer: C. Ask the client to describe the pain in more detail.
Rationale: Pain is a subjective experience, and the client's self-report is the most reliable indicator.
The nurse should accept the client's report and perform a comprehensive pain assessment (e.g.,
location, quality, aggravating and alleviating factors). Administering medication based solely on the
number without further assessment is premature. Documenting the discrepancy without exploring it
is an incomplete action. Switching scales may be confusing or unnecessary.
,4. During a sterile dressing change, a nurse drops the sterile gauze onto the client's bed. Which
action is most appropriate?
A. Pick up the gauze and use it, as it is still within the sterile field.
B. Place the gauze on the sterile field and continue; the bed is clean.
C. Discard the gauze and obtain a new sterile package.
D. Use the gauze but keep it away from the wound edges.
Correct Answer: C. Discard the gauze and obtain a new sterile package.
Rationale: Once a sterile item touches a non-sterile surface, it is contaminated and cannot be used.
This is a fundamental principle of surgical asepsis. The nurse must discard the gauze and get a new
one to maintain the integrity of the sterile field and prevent infection.
5. The healthcare provider prescribes a 1000 mL bag of normal saline to infuse over 8 hours. The
drop factor is 15 gtt/mL. At what rate in gtt/min should the nurse set the IV? (Round to the nearest
whole number.)
A. 31 gtt/min
B. 42 gtt/min
C. 21 gtt/min
D. 15 gtt/min
Correct Answer: A. 31 gtt/min
Rationale: The formula is (Total Volume x Drop Factor) / Time in Minutes. (1000 mL x 15 gtt/mL) / (8
hours x 60 minutes) = = 31.25, which rounds to 31 gtt/min. The other options are
incorrect calculations.
6. A client is two hours post-operative from a total hip arthroplasty. Which finding would be most
concerning to the nurse?
A. The client's pain is rated as a 6 out of 10.
B. The client's oral temperature is 99.2°F (37.3°C).
C. The client's hemoglobin level has dropped from 12 g/dL to 9 g/dL.
D. The client's urine output is 40 mL for the past hour.
Correct Answer: C. The client's hemoglobin level has dropped from 12 g/dL to 9 g/dL.
Rationale: A significant drop in hemoglobin post-operatively is a priority concern as it indicates
potential internal bleeding or hemorrhage. Pain, a low-grade fever, and a urine output of 40 mL/hr
(adequate) are expected findings after surgery and should be monitored but are not as immediately
critical as a 3 g/dL drop in hemoglobin.
7. The nurse is preparing to administer an intramuscular (IM) injection in the ventrogluteal site.
Which landmark is essential for locating this site accurately?
A. The greater trochanter and the iliac crest.
B. The acromion process and the scapula.
C. The anterior superior iliac spine and the iliac crest.
D. The heel of the hand on the greater trochanter, with the index finger pointing to the anterior
superior iliac spine.
Correct Answer: D. The heel of the hand on the greater trochanter, with the index finger pointing
to the anterior superior iliac spine.
Rationale: This is the correct landmarking technique for the ventrogluteal site. The nurse places the
heel of the hand on the greater trochanter, the index finger on the anterior superior iliac spine, and
,the middle finger points toward the iliac crest, forming a V. The injection is given in the center of the
V. The other options describe other injection sites or incorrect landmarks.
8. A client with heart failure is prescribed furosemide. Which laboratory value should the nurse
monitor most closely before administering this medication?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes significant potassium loss, which can lead to
hypokalemia. Hypokalemia can precipitate dangerous cardiac dysrhythmias, especially in clients with
heart failure who may also be taking digitalis. While sodium, calcium, and magnesium are important
to monitor, potassium is the primary electrolyte of concern with loop diuretics.
9. A nurse is providing discharge teaching to a client on a low-sodium diet. Which food choice by
the client indicates a need for further teaching?
A. Fresh apple
B. Grilled chicken breast
C. Canned vegetable soup
D. Brown rice
Correct Answer: C. Canned vegetable soup
Rationale: Canned soups are notoriously high in sodium, often containing a significant portion of the
daily recommended limit. Fresh fruit, plain grilled chicken, and brown rice are naturally low in sodium
and are appropriate choices for a low-sodium diet.
10. A nurse is caring for a client receiving continuous enteral nutrition via a PEG tube. The client
develops diarrhea. Which action should the nurse take first?
A. Slow the infusion rate of the feeding.
B. Obtain a stool sample for culture.
C. Check the osmolality of the formula.
D. Assess for medication side effects and recent antibiotic use.
Correct Answer: D. Assess for medication side effects and recent antibiotic use.
Rationale: The most common cause of diarrhea in a client receiving enteral feeding is medication side
effects (e.g., antibiotics, sorbitol elixirs) or C. difficile. A thorough assessment should be conducted to
identify the cause before adjusting the feeding rate, which is a common but not always first-line
intervention. Checking formula osmolality and obtaining a stool sample are appropriate but
subsequent steps.
11. An elderly client with dementia is at risk for falls. Which nursing intervention is most effective
in preventing injury?
A. Applying soft wrist restraints to prevent the client from getting out of bed.
B. Keeping the bed in the lowest position with the side rails up.
C. Implementing a toileting schedule to reduce the need for ambulation at night.
D. Placing a bedside commode and ensuring the call light is within reach.
Correct Answer: B. Keeping the bed in the lowest position with the side rails up.
Rationale: Maintaining the bed in the lowest position with the side rails up is a key environmental
, safety measure to minimize injury if the client attempts to get up. Restraints should be avoided as a
first-line measure. While a toileting schedule is helpful, it does not directly prevent injury from falls
that still occur. A commode and call light are useful but don't address the immediate risk of falling
from a high bed.
12. A nurse is assessing a client who is 24 hours post-op. The client's surgical site is red, warm, and
painful. What is the nurse's priority action?
A. Apply a cold compress to the site.
B. Document the findings as a normal inflammatory response.
C. Assess the client's temperature and white blood cell count.
D. Remove the dressing and assess the wound for dehiscence.
Correct Answer: C. Assess the client's temperature and white blood cell count.
Rationale: While redness, warmth, and pain are expected in the first 24-48 hours as part of the
inflammatory process, the priority is to rule out infection. The nurse should assess for systemic signs
of infection (fever, elevated WBCs) to differentiate a normal response from an infection. Applying a
cold compress or removing the dressing is premature. Documenting without further assessment is
insufficient.
13. A client refuses a scheduled dose of oral pain medication. Which of the following actions by the
nurse is most appropriate?
A. Crush the medication and mix it with applesauce without telling the client.
B. Call the healthcare provider to report the refusal.
C. Document the refusal and re-assess the client's pain in one hour.
D. Leave the medication at the bedside in case the client changes their mind.
Correct Answer: C. Document the refusal and re-assess the client's pain in one hour.
Rationale: A client has the right to refuse medication. The nurse must respect this decision, document
the refusal, and continue to assess and re-evaluate the client's needs. Crushing medication or leaving
it at the bedside is unsafe and violates ethical principles. Calling the healthcare provider is not
necessary for a single refusal unless the client consistently refuses.
14. A nurse is preparing to perform a sterile urinary catheterization. Which of the following actions
would violate sterile technique?
A. Using sterile gloves and a sterile drape.
B. Opening the catheter kit away from the sterile field.
C. Pouring sterile water into the sterile basin.
D. Placing the sterile catheter onto the sterile field.
Correct Answer: B. Opening the catheter kit away from the sterile field.
Rationale: The outer wrapper of the sterile kit is considered contaminated. It must be opened away
from the sterile field to prevent contaminating the field with the dust and microorganisms that may
have settled on the wrapper. The other options are correct sterile technique practices.
15. A nurse is calculating the intake and output for a client. The client drank 240 mL of juice, 120
mL of water, and ate 180 mL of ice cream. The client also has an IV of 100 mL/hr running for 8
hours. What is the total intake in mL?
A. 540 mL
B. 800 mL
C. 1140 mL
D. 1260 mL
VERIFIED ANSWERS | 2026–2027 LATEST UPDATE |
GUARANTEED PASS | DETAILED RATIONALES | FULL STUDY
GUIDE | EXAM PREP | PRACTICE TEST | CERTIFICATION
PREPARATION
Section One: Questions 1–100
1. A nurse is preparing to administer an enteral feeding to a client via a nasogastric (NG) tube.
Which action should the nurse take first to ensure safe administration?
A. Flush the tube with 30 mL of warm water.
B. Verify the placement of the tube by measuring the pH of the gastric aspirate.
C. Place the client in a supine position.
D. Check the residual volume to assess for delayed gastric emptying.
Correct Answer: B. Verify the placement of the tube by measuring the pH of the gastric aspirate.
Rationale: The priority action before any enteral feeding is to confirm the correct placement of the
tube to prevent accidental administration into the lungs. Measuring the pH of gastric aspirate
(typically 4 or less) is a reliable method to confirm gastric placement. Flushing and checking residual
are important but should occur after placement is verified. The client should be positioned in a semi-
Fowler's or high-Fowler's position (not supine) to reduce the risk of aspiration.
2. A client with a new colostomy is being discharged. Which statement by the client indicates a
correct understanding of dietary management?
A. "I should avoid all high-fiber foods to prevent blockage."
B. "I can eat any food as long as I chew it thoroughly."
C. "I should increase my intake of foods that cause gas, like beans and broccoli."
D. "I will need to take a daily laxative to ensure regular bowel movements."
Correct Answer: B. "I can eat any food as long as I chew it thoroughly."
Rationale: Clients with a new colostomy are often advised that they can return to a normal diet, but
they must chew food thoroughly to prevent blockage. While some foods may cause gas or odor, they
are not strictly prohibited. A high-fiber diet is not entirely avoided; it is introduced gradually.
Laxatives are not typically required and could cause complications.
3. A nurse is assessing a client's pain level. The client reports a "4" on a 0-10 pain scale but is
smiling and watching television. What is the nurse's best initial action?
A. Administer the prescribed analgesic immediately.
B. Document the discrepancy and re-evaluate in an hour.
C. Ask the client to describe the pain in more detail.
D. Use a different pain scale to validate the finding.
Correct Answer: C. Ask the client to describe the pain in more detail.
Rationale: Pain is a subjective experience, and the client's self-report is the most reliable indicator.
The nurse should accept the client's report and perform a comprehensive pain assessment (e.g.,
location, quality, aggravating and alleviating factors). Administering medication based solely on the
number without further assessment is premature. Documenting the discrepancy without exploring it
is an incomplete action. Switching scales may be confusing or unnecessary.
,4. During a sterile dressing change, a nurse drops the sterile gauze onto the client's bed. Which
action is most appropriate?
A. Pick up the gauze and use it, as it is still within the sterile field.
B. Place the gauze on the sterile field and continue; the bed is clean.
C. Discard the gauze and obtain a new sterile package.
D. Use the gauze but keep it away from the wound edges.
Correct Answer: C. Discard the gauze and obtain a new sterile package.
Rationale: Once a sterile item touches a non-sterile surface, it is contaminated and cannot be used.
This is a fundamental principle of surgical asepsis. The nurse must discard the gauze and get a new
one to maintain the integrity of the sterile field and prevent infection.
5. The healthcare provider prescribes a 1000 mL bag of normal saline to infuse over 8 hours. The
drop factor is 15 gtt/mL. At what rate in gtt/min should the nurse set the IV? (Round to the nearest
whole number.)
A. 31 gtt/min
B. 42 gtt/min
C. 21 gtt/min
D. 15 gtt/min
Correct Answer: A. 31 gtt/min
Rationale: The formula is (Total Volume x Drop Factor) / Time in Minutes. (1000 mL x 15 gtt/mL) / (8
hours x 60 minutes) = = 31.25, which rounds to 31 gtt/min. The other options are
incorrect calculations.
6. A client is two hours post-operative from a total hip arthroplasty. Which finding would be most
concerning to the nurse?
A. The client's pain is rated as a 6 out of 10.
B. The client's oral temperature is 99.2°F (37.3°C).
C. The client's hemoglobin level has dropped from 12 g/dL to 9 g/dL.
D. The client's urine output is 40 mL for the past hour.
Correct Answer: C. The client's hemoglobin level has dropped from 12 g/dL to 9 g/dL.
Rationale: A significant drop in hemoglobin post-operatively is a priority concern as it indicates
potential internal bleeding or hemorrhage. Pain, a low-grade fever, and a urine output of 40 mL/hr
(adequate) are expected findings after surgery and should be monitored but are not as immediately
critical as a 3 g/dL drop in hemoglobin.
7. The nurse is preparing to administer an intramuscular (IM) injection in the ventrogluteal site.
Which landmark is essential for locating this site accurately?
A. The greater trochanter and the iliac crest.
B. The acromion process and the scapula.
C. The anterior superior iliac spine and the iliac crest.
D. The heel of the hand on the greater trochanter, with the index finger pointing to the anterior
superior iliac spine.
Correct Answer: D. The heel of the hand on the greater trochanter, with the index finger pointing
to the anterior superior iliac spine.
Rationale: This is the correct landmarking technique for the ventrogluteal site. The nurse places the
heel of the hand on the greater trochanter, the index finger on the anterior superior iliac spine, and
,the middle finger points toward the iliac crest, forming a V. The injection is given in the center of the
V. The other options describe other injection sites or incorrect landmarks.
8. A client with heart failure is prescribed furosemide. Which laboratory value should the nurse
monitor most closely before administering this medication?
A. Serum sodium
B. Serum potassium
C. Serum calcium
D. Serum magnesium
Correct Answer: B. Serum potassium
Rationale: Furosemide is a loop diuretic that causes significant potassium loss, which can lead to
hypokalemia. Hypokalemia can precipitate dangerous cardiac dysrhythmias, especially in clients with
heart failure who may also be taking digitalis. While sodium, calcium, and magnesium are important
to monitor, potassium is the primary electrolyte of concern with loop diuretics.
9. A nurse is providing discharge teaching to a client on a low-sodium diet. Which food choice by
the client indicates a need for further teaching?
A. Fresh apple
B. Grilled chicken breast
C. Canned vegetable soup
D. Brown rice
Correct Answer: C. Canned vegetable soup
Rationale: Canned soups are notoriously high in sodium, often containing a significant portion of the
daily recommended limit. Fresh fruit, plain grilled chicken, and brown rice are naturally low in sodium
and are appropriate choices for a low-sodium diet.
10. A nurse is caring for a client receiving continuous enteral nutrition via a PEG tube. The client
develops diarrhea. Which action should the nurse take first?
A. Slow the infusion rate of the feeding.
B. Obtain a stool sample for culture.
C. Check the osmolality of the formula.
D. Assess for medication side effects and recent antibiotic use.
Correct Answer: D. Assess for medication side effects and recent antibiotic use.
Rationale: The most common cause of diarrhea in a client receiving enteral feeding is medication side
effects (e.g., antibiotics, sorbitol elixirs) or C. difficile. A thorough assessment should be conducted to
identify the cause before adjusting the feeding rate, which is a common but not always first-line
intervention. Checking formula osmolality and obtaining a stool sample are appropriate but
subsequent steps.
11. An elderly client with dementia is at risk for falls. Which nursing intervention is most effective
in preventing injury?
A. Applying soft wrist restraints to prevent the client from getting out of bed.
B. Keeping the bed in the lowest position with the side rails up.
C. Implementing a toileting schedule to reduce the need for ambulation at night.
D. Placing a bedside commode and ensuring the call light is within reach.
Correct Answer: B. Keeping the bed in the lowest position with the side rails up.
Rationale: Maintaining the bed in the lowest position with the side rails up is a key environmental
, safety measure to minimize injury if the client attempts to get up. Restraints should be avoided as a
first-line measure. While a toileting schedule is helpful, it does not directly prevent injury from falls
that still occur. A commode and call light are useful but don't address the immediate risk of falling
from a high bed.
12. A nurse is assessing a client who is 24 hours post-op. The client's surgical site is red, warm, and
painful. What is the nurse's priority action?
A. Apply a cold compress to the site.
B. Document the findings as a normal inflammatory response.
C. Assess the client's temperature and white blood cell count.
D. Remove the dressing and assess the wound for dehiscence.
Correct Answer: C. Assess the client's temperature and white blood cell count.
Rationale: While redness, warmth, and pain are expected in the first 24-48 hours as part of the
inflammatory process, the priority is to rule out infection. The nurse should assess for systemic signs
of infection (fever, elevated WBCs) to differentiate a normal response from an infection. Applying a
cold compress or removing the dressing is premature. Documenting without further assessment is
insufficient.
13. A client refuses a scheduled dose of oral pain medication. Which of the following actions by the
nurse is most appropriate?
A. Crush the medication and mix it with applesauce without telling the client.
B. Call the healthcare provider to report the refusal.
C. Document the refusal and re-assess the client's pain in one hour.
D. Leave the medication at the bedside in case the client changes their mind.
Correct Answer: C. Document the refusal and re-assess the client's pain in one hour.
Rationale: A client has the right to refuse medication. The nurse must respect this decision, document
the refusal, and continue to assess and re-evaluate the client's needs. Crushing medication or leaving
it at the bedside is unsafe and violates ethical principles. Calling the healthcare provider is not
necessary for a single refusal unless the client consistently refuses.
14. A nurse is preparing to perform a sterile urinary catheterization. Which of the following actions
would violate sterile technique?
A. Using sterile gloves and a sterile drape.
B. Opening the catheter kit away from the sterile field.
C. Pouring sterile water into the sterile basin.
D. Placing the sterile catheter onto the sterile field.
Correct Answer: B. Opening the catheter kit away from the sterile field.
Rationale: The outer wrapper of the sterile kit is considered contaminated. It must be opened away
from the sterile field to prevent contaminating the field with the dust and microorganisms that may
have settled on the wrapper. The other options are correct sterile technique practices.
15. A nurse is calculating the intake and output for a client. The client drank 240 mL of juice, 120
mL of water, and ate 180 mL of ice cream. The client also has an IV of 100 mL/hr running for 8
hours. What is the total intake in mL?
A. 540 mL
B. 800 mL
C. 1140 mL
D. 1260 mL
