HESI FUNDAMENTALS RN STUDY GUIDE
TEST BANK Q/A(S)/ 2022-2023 UPDATE
SECTION I: NURSING PROCESS & CRITICAL THINKING
1. The nurse is caring for a postoperative patient who reports incisional pain rated 7/10.
Which action should the nurse take FIRST?
A. Assess the pain characteristics, location, and aggravating factors
Rationale: The nursing process begins with assessment. Before intervening, the nurse must
thoroughly assess the pain. While administering analgesia may be appropriate, assessment
must come first to ensure proper intervention and evaluation.
B. Administer the prescribed opioid analgesic immediately
C. Reposition the patient to promote comfort
D. Document the pain level in the electronic health record
2. A nurse is evaluating a patient's response to a newly prescribed antihypertensive
medication. Which finding best indicates the medication is effective?
A. Patient reports feeling less anxious
B. Patient's heart rate is 88 bpm
C. Blood pressure decreased from 168/94 to 138/86 mm Hg
Rationale: The desired outcome for antihypertensive therapy is a reduction in blood
pressure toward normal limits. Evaluating the BP change directly reflects therapeutic
effectiveness.
D. Patient denies headache
3. Which statement by the nurse demonstrates the "Evaluation" phase of the nursing
process?
A. "The patient's oxygen saturation is 89% on room air."
B. "The patient will maintain a patent airway."
C. "I will elevate the head of the bed to 45 degrees."
D. "The patient met the goal of ambulating 50 feet without dyspnea."
Rationale: Evaluation determines whether the patient has met the established
,goals/outcomes. Comparing actual outcomes to expected outcomes is the essence of
evaluation.
4. The nurse is prioritizing care for four patients. Which patient should the nurse assess FIRST?
A. A patient requesting pain medication for chronic back pain rated 5/10
B. A patient who needs assistance with ambulation to the bathroom
C. A patient who is 2 days postoperative with a sudden drop in blood pressure and
confusion
Rationale: Using Maslow's hierarchy and ABC priority framework, a patient with signs of
shock (hypotension and new-onset confusion) is the most unstable and requires immediate
assessment.
D. A patient asking questions about discharge instructions
5. A nurse is revising a care plan for a patient whose goal was not met. Which action reflects
appropriate use of the nursing process?
A. Continue the same interventions without changes
B. Discharge the patient since the goal was not met
C. Reassess the patient and modify interventions as needed
Rationale: When goals are not met, the nurse reassesses, identifies barriers, and revises the
plan of care. The nursing process is dynamic and cyclical.
D. Document that the patient is noncompliant
6. Which of the following are components of a properly written nursing diagnosis? (SATA)
A. Problem statement (NANDA-I label)
B. Etiology (related to)
C. Defining characteristics (as evidenced by)
D. Medical diagnosis
E. Surgeon's orders
Rationale: A nursing diagnosis consists of the problem, etiology, and defining characteristics
(PES format). Medical diagnoses and physician orders are not components of a nursing
diagnosis.
,7. The nurse is using critical thinking to make a clinical decision. Which action demonstrates
the highest level of critical thinking?
A. Following the provider's orders without question
B. Performing tasks in the order they are received
C. Analyzing data, considering alternatives, and evaluating outcomes before acting
Rationale: Critical thinking involves purposeful, outcome-directed reasoning. Analyzing
data, weighing alternatives, and evaluating potential outcomes reflect higher-order clinical
judgment.
D. Relying on past experiences only
8. A patient states, "I don't understand why I need to take this medication." What is the
nurse's BEST response?
A. "Your doctor ordered it, so you need to take it."
B. "Let me explain how this medication works and why it was prescribed for you."
Rationale: The nurse should provide patient education and advocate for understanding.
Explaining the medication's purpose respects autonomy and promotes adherence.
C. "You can refuse if you want to."
D. "I'll have the doctor explain it to you later."
9. Which outcome statement is written correctly?
A. "The patient will understand his disease process."
B. "The patient will verbalize three signs of wound infection by discharge."
Rationale: Correctly written outcomes are patient-centered, measurable, time-specific, and
observable. Verbalizing three signs is measurable and has a time frame.
C. "The nurse will teach the patient about infection."
D. "The patient will feel better soon."
10. During the assessment phase, the nurse collects which type of data when asking the
patient about their pain?
, A. Objective data only
B. Subjective data
Rationale: Subjective data includes information the patient reports, such as pain, nausea,
and feelings. Objective data is directly observable or measurable by the nurse.
C. Secondary data only
D. Diagnostic data
SECTION II: SAFETY & INFECTION CONTROL
11. The nurse is preparing to care for a patient with Clostridioides difficile (C. diff). Which PPE
is required?
A. Gloves only
B. Gloves and mask
C. Gloves and gown
Rationale: C. diff requires contact precautions. Gloves and gown must be worn for all
contact with the patient or contaminated surfaces. Hand hygiene with soap and water (not
alcohol-based) is essential.
D. Gloves, gown, mask, and eye protection
12. A nurse is performing hand hygiene. Which situation requires the use of soap and water
rather than alcohol-based hand sanitizer?
A. Before touching a patient
B. After removing gloves
C. After caring for a patient with C. difficile
Rationale: Alcohol-based hand sanitizers are ineffective against C. diff spores. Soap and
water mechanically remove spores and must be used in this situation.
D. Before donning sterile gloves
13. Which patient is at GREATEST risk for falls?
A. A 30-year-old with a fractured arm
B. A 45-year-old 1 day postoperative hernia repair
C. An 82-year-old taking a diuretic and a benzodiazepine
TEST BANK Q/A(S)/ 2022-2023 UPDATE
SECTION I: NURSING PROCESS & CRITICAL THINKING
1. The nurse is caring for a postoperative patient who reports incisional pain rated 7/10.
Which action should the nurse take FIRST?
A. Assess the pain characteristics, location, and aggravating factors
Rationale: The nursing process begins with assessment. Before intervening, the nurse must
thoroughly assess the pain. While administering analgesia may be appropriate, assessment
must come first to ensure proper intervention and evaluation.
B. Administer the prescribed opioid analgesic immediately
C. Reposition the patient to promote comfort
D. Document the pain level in the electronic health record
2. A nurse is evaluating a patient's response to a newly prescribed antihypertensive
medication. Which finding best indicates the medication is effective?
A. Patient reports feeling less anxious
B. Patient's heart rate is 88 bpm
C. Blood pressure decreased from 168/94 to 138/86 mm Hg
Rationale: The desired outcome for antihypertensive therapy is a reduction in blood
pressure toward normal limits. Evaluating the BP change directly reflects therapeutic
effectiveness.
D. Patient denies headache
3. Which statement by the nurse demonstrates the "Evaluation" phase of the nursing
process?
A. "The patient's oxygen saturation is 89% on room air."
B. "The patient will maintain a patent airway."
C. "I will elevate the head of the bed to 45 degrees."
D. "The patient met the goal of ambulating 50 feet without dyspnea."
Rationale: Evaluation determines whether the patient has met the established
,goals/outcomes. Comparing actual outcomes to expected outcomes is the essence of
evaluation.
4. The nurse is prioritizing care for four patients. Which patient should the nurse assess FIRST?
A. A patient requesting pain medication for chronic back pain rated 5/10
B. A patient who needs assistance with ambulation to the bathroom
C. A patient who is 2 days postoperative with a sudden drop in blood pressure and
confusion
Rationale: Using Maslow's hierarchy and ABC priority framework, a patient with signs of
shock (hypotension and new-onset confusion) is the most unstable and requires immediate
assessment.
D. A patient asking questions about discharge instructions
5. A nurse is revising a care plan for a patient whose goal was not met. Which action reflects
appropriate use of the nursing process?
A. Continue the same interventions without changes
B. Discharge the patient since the goal was not met
C. Reassess the patient and modify interventions as needed
Rationale: When goals are not met, the nurse reassesses, identifies barriers, and revises the
plan of care. The nursing process is dynamic and cyclical.
D. Document that the patient is noncompliant
6. Which of the following are components of a properly written nursing diagnosis? (SATA)
A. Problem statement (NANDA-I label)
B. Etiology (related to)
C. Defining characteristics (as evidenced by)
D. Medical diagnosis
E. Surgeon's orders
Rationale: A nursing diagnosis consists of the problem, etiology, and defining characteristics
(PES format). Medical diagnoses and physician orders are not components of a nursing
diagnosis.
,7. The nurse is using critical thinking to make a clinical decision. Which action demonstrates
the highest level of critical thinking?
A. Following the provider's orders without question
B. Performing tasks in the order they are received
C. Analyzing data, considering alternatives, and evaluating outcomes before acting
Rationale: Critical thinking involves purposeful, outcome-directed reasoning. Analyzing
data, weighing alternatives, and evaluating potential outcomes reflect higher-order clinical
judgment.
D. Relying on past experiences only
8. A patient states, "I don't understand why I need to take this medication." What is the
nurse's BEST response?
A. "Your doctor ordered it, so you need to take it."
B. "Let me explain how this medication works and why it was prescribed for you."
Rationale: The nurse should provide patient education and advocate for understanding.
Explaining the medication's purpose respects autonomy and promotes adherence.
C. "You can refuse if you want to."
D. "I'll have the doctor explain it to you later."
9. Which outcome statement is written correctly?
A. "The patient will understand his disease process."
B. "The patient will verbalize three signs of wound infection by discharge."
Rationale: Correctly written outcomes are patient-centered, measurable, time-specific, and
observable. Verbalizing three signs is measurable and has a time frame.
C. "The nurse will teach the patient about infection."
D. "The patient will feel better soon."
10. During the assessment phase, the nurse collects which type of data when asking the
patient about their pain?
, A. Objective data only
B. Subjective data
Rationale: Subjective data includes information the patient reports, such as pain, nausea,
and feelings. Objective data is directly observable or measurable by the nurse.
C. Secondary data only
D. Diagnostic data
SECTION II: SAFETY & INFECTION CONTROL
11. The nurse is preparing to care for a patient with Clostridioides difficile (C. diff). Which PPE
is required?
A. Gloves only
B. Gloves and mask
C. Gloves and gown
Rationale: C. diff requires contact precautions. Gloves and gown must be worn for all
contact with the patient or contaminated surfaces. Hand hygiene with soap and water (not
alcohol-based) is essential.
D. Gloves, gown, mask, and eye protection
12. A nurse is performing hand hygiene. Which situation requires the use of soap and water
rather than alcohol-based hand sanitizer?
A. Before touching a patient
B. After removing gloves
C. After caring for a patient with C. difficile
Rationale: Alcohol-based hand sanitizers are ineffective against C. diff spores. Soap and
water mechanically remove spores and must be used in this situation.
D. Before donning sterile gloves
13. Which patient is at GREATEST risk for falls?
A. A 30-year-old with a fractured arm
B. A 45-year-old 1 day postoperative hernia repair
C. An 82-year-old taking a diuretic and a benzodiazepine
