Foundations of Nursing HESI Exam 1 Practice Exam - Complete Questions & Verified Answers - Infection Control &
Clinical Skills Mastery - Herzing University LPN
Herzing University LPN | Foundations of Nursing HESI Exam 1 | Complete Questions Verified Answers Grade A | Different
Title 2
TABLE OF CONTENTS
1. I. Foundations of Nursing Fundamentals - Nursing Process ADPIE, Maslow Hierarchy, Safety
2. II. Infection Control - Hand Hygiene Soap Water 20 Seconds vs Alcohol Sanitizer, PPE Donning Doffing Gown Mask Goggles Gloves,
Standard Precautions
3. III. Isolation Precautions - Contact MRSA Wound Gown Gloves, Droplet Influenza Surgical Mask 3 Feet, Airborne TB N95 Private Room
4. IV. Patient Safety - Fall Prevention Morse Fall Scale >45 High Risk Bed Alarm Hourly Rounding Nonslip, Restraints Last Resort, Confusion
Assessment Reorientation
5. V. Skin Integrity - Braden Scale <18 At Risk <16 Moderate <12 High Risk, Pressure Injury Stages Stage1 Intact Redness Stage2 Partial
Thickness Dermis Blister Stage3 Full Thickness Fat Stage4 Bone Muscle Unstageable Slough
6. VI. Mobility and Body Mechanics - Safe Transfer Wide Base Bend Knees Client Close Gait Belt Lock Wheelchair, Reposition q2h Bony
Prominences
7. VII. Hygiene and ADLs - Bathing Privacy Draping, ADLs Bathing Dressing Toileting Feeding Ambulation Grooming, Bed Bath Principles
Dignity
8. VIII. Medication Administration via NG Tube - Check Placement Flush 15-30mL Separate Meds Don't Crush Enteric Coated ER
Compatibility
9. IX. Intake and Output - Conversion 1 oz=30 mL, Strict I&O; Documentation, Fluid Overload Crackles Edema Dyspnea Weight Gain Elevated
BP JVD
10. X. Elimination - CAUTI Prevention Closed Drainage Bag Below Bladder Above Floor No Kinks Perineal Hygiene Early Removal
11. XI. Respiratory Care - Incentive Spirometer Prevent Atelectasis 10 Breaths Per Hour Splint Incision, SCDs Apply Check Circulation
12. XII. Documentation - SOAPIE Subjective Objective Assessment Plan Intervention Evaluation, Charting Principles
13. XIII. Professional Standards - Peer Accountability Hand Hygiene Remind Privately Chain, Client Advocacy
14. XIV. Practice Questions - Complete Questions Each Asked Like Real HESI Exam 1
15. XV. Answer Key with Detailed Rationales - Grade A
,FOUNDATIONS OF NURSING HESI EXAM 1 - PRACTICE QUESTIONS - EACH QUESTION ASKED LIKE REAL EXAM
Based on Herzing University LPN Foundations of Nursing HESI Exam 1 Blueprint - Fundamentals of Care Safety Infection Control Mobility Documentation. High Yield.
1. A nurse is caring for a client with indwelling urinary catheter. What action prevents CAUTI?
A. Leave bag on floor
B. Open system frequently
C. Maintain closed drainage system, bag below bladder above floor, no kinks, perineal hygiene, remove as soon as possible, hand hygiene
D. No hygiene needed
Answer: C
Rationale: CAUTI prevention: closed system, bag below bladder above floor, no kinks, perineal hygiene, early removal, hand hygiene.
2. A nurse is preparing to give bed bath. What principle maintains client dignity?
A. Expose entire body
B. Provide privacy, drape, warm water, explain, allow participation, keep warm, respect
C. Cold water
D. No privacy
Answer: B
Rationale: Bed bath privacy draping warm water explain participation dignity.
3. A client has an order for sequential compression devices (SCDs). What should nurse do?
A. Never remove
B. No check needed
C. Leave off continuously
D. Apply properly, remove for skin assessment, check circulation, ensure sleeves not kinked, use while in bed, ambulation when off
Answer: D
Rationale: SCDs apply properly, remove for skin check circulation check kinks use while in bed.
4. A client is on strict intake and output. The client drank 4 oz juice, 8 oz coffee, and voided 350 mL. How should the nurse document intake?
A. 350 mL intake
B. No intake
C. 4 oz intake
D. 360 mL intake - 4 oz = 120 mL, 8 oz = 240 mL, total 360 mL intake, output 350 mL
Answer: D
Rationale: I&O; conversion 1 oz=30 mL, 4 oz=120, 8 oz=240 total 360 mL intake.
5. A nurse is caring for a client with impaired mobility. The client has a Braden Scale score of 12. Which intervention should the nurse prioritize
to prevent pressure injury?
A. Reposition every 2 hours, assess bony prominences, keep skin dry, use pressure-relieving mattress, nutrition consult - Braden 12 high risk
B. Only apply lotion
C. No intervention needed
D. Reposition every 4 hours
Answer: A
Rationale: Braden 12 high risk (<18 at risk, <16 moderate, <12 high). Priority q2h repositioning, skin assessment, moisture control, pressure relief,
nutrition.
6. A nurse is documenting using SOAPIE. What does it include?
A. Only subjective
B. Only objective
C. Subjective Objective Assessment Plan Intervention Evaluation - comprehensive charting
D. No plan
Answer: C
Rationale: SOAPIE Subjective Objective Assessment Plan Intervention Evaluation.
7. A nurse observes another nurse not performing hand hygiene before client contact. What is appropriate action?
A. No action
B. Yell publicly
C. Ignore
D. Speak privately, remind of policy, offer support, report if pattern continues via chain, advocate for client safety
Answer: D
Rationale: Peer not performing hand hygiene address privately remind policy support chain if pattern advocate safety.
8. A client reports pain 8/10. The nurse assesses OLDCARTS. What does this include?
A. No assessment
B. Only location
C. Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity - comprehensive pain assessment
D. Only severity
Answer: C
Rationale: OLDCARTS pain: Onset Location Duration Character Aggravating Alleviating Radiation Timing Severity.
9. A client is confused and attempting to get out of bed. What is nurse's priority?
, A. Assess cause confusion, reorient, ensure safety bed alarm low bed, nonslip, address needs pain toileting, consider sitter, last resort restraints with
order
B. Ignore
C. Apply restraints immediately
D. Leave alone
Answer: A
Rationale: Confused client safety priority assess cause reorient bed alarm low bed address needs sitter restraints last resort with order.
10. A client is on contact precautions for MRSA wound infection. What PPE should nurse wear?
A. Only mask
B. Gown and gloves, don before entering, doff before exiting, hand hygiene, private room or cohort
C. Only gloves
D. No PPE
Answer: B
Rationale: Contact precautions MRSA wound: gown and gloves don before entering doff before exiting hand hygiene private room.
11. A client has stage 2 pressure injury on sacrum. What is description?
A. Unstageable
B. Partial thickness skin loss with exposed dermis, blister or shallow crater pink-red moist, no slough, no fat visible
C. Intact skin redness
D. Full thickness with bone
Answer: B
Rationale: Stage2 partial thickness dermis exposed pink-red moist blister shallow crater no slough fat.
12. A nurse is documenting using SOAPIE. What does it include?
A. Only objective
B. No plan
C. Only subjective
D. Subjective Objective Assessment Plan Intervention Evaluation - comprehensive charting
Answer: D
Rationale: SOAPIE Subjective Objective Assessment Plan Intervention Evaluation.
13. A client has stage 2 pressure injury on sacrum. What is description?
A. Partial thickness skin loss with exposed dermis, blister or shallow crater pink-red moist, no slough, no fat visible
B. Full thickness with bone
C. Unstageable
D. Intact skin redness
Answer: A
Rationale: Stage2 partial thickness dermis exposed pink-red moist blister shallow crater no slough fat.
14. A nurse is preparing to give bed bath. What principle maintains client dignity?
A. Cold water
B. Expose entire body
C. Provide privacy, drape, warm water, explain, allow participation, keep warm, respect
D. No privacy
Answer: C
Rationale: Bed bath privacy draping warm water explain participation dignity.
15. A nurse is caring for client on droplet precautions for influenza. What is required?
A. Only gloves
B. Private room and N95
C. Private room or cohort, surgical mask within 3 feet, hand hygiene, limit transport, mask on client when transported
D. No mask
Answer: C
Rationale: Droplet influenza private room cohort surgical mask within 3ft hand hygiene mask on client transport.
16. A nurse is preparing to administer medications through a nasogastric tube. What is the correct action to ensure safe administration?
A. Check placement, flush 15-30mL water before and after each med, give meds separately, don't crush enteric-coated/ER, check compatibility
B. Mix all meds together
C. Crush all enteric-coated meds together
D. Give without flushing
Answer: A
Rationale: NG meds: check placement, flush before/after each med 15-30mL, separate administration, don't crush enteric-coated ER, check
compatibility.
17. A nurse is caring for a client with indwelling urinary catheter. What action prevents CAUTI?
A. No hygiene needed
B. Open system frequently
C. Maintain closed drainage system, bag below bladder above floor, no kinks, perineal hygiene, remove as soon as possible, hand hygiene
D. Leave bag on floor
, Answer: C
Rationale: CAUTI prevention: closed system, bag below bladder above floor, no kinks, perineal hygiene, early removal, hand hygiene.
18. A client has an order for sequential compression devices (SCDs). What should nurse do?
A. Never remove
B. Leave off continuously
C. Apply properly, remove for skin assessment, check circulation, ensure sleeves not kinked, use while in bed, ambulation when off
D. No check needed
Answer: C
Rationale: SCDs apply properly, remove for skin check circulation check kinks use while in bed.
19. A client is confused and attempting to get out of bed. What is nurse's priority?
A. Assess cause confusion, reorient, ensure safety bed alarm low bed, nonslip, address needs pain toileting, consider sitter, last resort restraints with
order
B. Apply restraints immediately
C. Ignore
D. Leave alone
Answer: A
Rationale: Confused client safety priority assess cause reorient bed alarm low bed address needs sitter restraints last resort with order.
20. What is correct order for donning PPE?
A. No order
B. Gloves first
C. Hand hygiene, gown, mask, goggles, gloves - donning
D. Mask first
Answer: C
Rationale: Donning: hand hygiene gown mask goggles gloves. Doffing: gloves goggles gown mask hand hygiene.
21. A client reports pain 8/10. The nurse assesses OLDCARTS. What does this include?
A. Only location
B. Only severity
C. Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity - comprehensive pain assessment
D. No assessment
Answer: C
Rationale: OLDCARTS pain: Onset Location Duration Character Aggravating Alleviating Radiation Timing Severity.
22. A client reports pain 8/10. The nurse assesses OLDCARTS. What does this include?
A. Only severity
B. Only location
C. Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity - comprehensive pain assessment
D. No assessment
Answer: C
Rationale: OLDCARTS pain: Onset Location Duration Character Aggravating Alleviating Radiation Timing Severity.
23. A client needs assistance with ADLs. What does ADL include?
A. No ADL
B. Only work
C. Only medications
D. Activities of Daily Living - bathing, dressing, toileting, feeding, ambulation, grooming
Answer: D
Rationale: ADL bathing dressing toileting feeding ambulation grooming.
24. A client has stage 2 pressure injury on sacrum. What is description?
A. Intact skin redness
B. Unstageable
C. Partial thickness skin loss with exposed dermis, blister or shallow crater pink-red moist, no slough, no fat visible
D. Full thickness with bone
Answer: C
Rationale: Stage2 partial thickness dermis exposed pink-red moist blister shallow crater no slough fat.
25. A client is confused and attempting to get out of bed. What is nurse's priority?
A. Apply restraints immediately
B. Ignore
C. Leave alone
D. Assess cause confusion, reorient, ensure safety bed alarm low bed, nonslip, address needs pain toileting, consider sitter, last resort restraints with
order
Answer: D
Rationale: Confused client safety priority assess cause reorient bed alarm low bed address needs sitter restraints last resort with order.
26. A nurse is caring for a client who is NPO and receiving IV fluids. What indicates fluid overload?
Clinical Skills Mastery - Herzing University LPN
Herzing University LPN | Foundations of Nursing HESI Exam 1 | Complete Questions Verified Answers Grade A | Different
Title 2
TABLE OF CONTENTS
1. I. Foundations of Nursing Fundamentals - Nursing Process ADPIE, Maslow Hierarchy, Safety
2. II. Infection Control - Hand Hygiene Soap Water 20 Seconds vs Alcohol Sanitizer, PPE Donning Doffing Gown Mask Goggles Gloves,
Standard Precautions
3. III. Isolation Precautions - Contact MRSA Wound Gown Gloves, Droplet Influenza Surgical Mask 3 Feet, Airborne TB N95 Private Room
4. IV. Patient Safety - Fall Prevention Morse Fall Scale >45 High Risk Bed Alarm Hourly Rounding Nonslip, Restraints Last Resort, Confusion
Assessment Reorientation
5. V. Skin Integrity - Braden Scale <18 At Risk <16 Moderate <12 High Risk, Pressure Injury Stages Stage1 Intact Redness Stage2 Partial
Thickness Dermis Blister Stage3 Full Thickness Fat Stage4 Bone Muscle Unstageable Slough
6. VI. Mobility and Body Mechanics - Safe Transfer Wide Base Bend Knees Client Close Gait Belt Lock Wheelchair, Reposition q2h Bony
Prominences
7. VII. Hygiene and ADLs - Bathing Privacy Draping, ADLs Bathing Dressing Toileting Feeding Ambulation Grooming, Bed Bath Principles
Dignity
8. VIII. Medication Administration via NG Tube - Check Placement Flush 15-30mL Separate Meds Don't Crush Enteric Coated ER
Compatibility
9. IX. Intake and Output - Conversion 1 oz=30 mL, Strict I&O; Documentation, Fluid Overload Crackles Edema Dyspnea Weight Gain Elevated
BP JVD
10. X. Elimination - CAUTI Prevention Closed Drainage Bag Below Bladder Above Floor No Kinks Perineal Hygiene Early Removal
11. XI. Respiratory Care - Incentive Spirometer Prevent Atelectasis 10 Breaths Per Hour Splint Incision, SCDs Apply Check Circulation
12. XII. Documentation - SOAPIE Subjective Objective Assessment Plan Intervention Evaluation, Charting Principles
13. XIII. Professional Standards - Peer Accountability Hand Hygiene Remind Privately Chain, Client Advocacy
14. XIV. Practice Questions - Complete Questions Each Asked Like Real HESI Exam 1
15. XV. Answer Key with Detailed Rationales - Grade A
,FOUNDATIONS OF NURSING HESI EXAM 1 - PRACTICE QUESTIONS - EACH QUESTION ASKED LIKE REAL EXAM
Based on Herzing University LPN Foundations of Nursing HESI Exam 1 Blueprint - Fundamentals of Care Safety Infection Control Mobility Documentation. High Yield.
1. A nurse is caring for a client with indwelling urinary catheter. What action prevents CAUTI?
A. Leave bag on floor
B. Open system frequently
C. Maintain closed drainage system, bag below bladder above floor, no kinks, perineal hygiene, remove as soon as possible, hand hygiene
D. No hygiene needed
Answer: C
Rationale: CAUTI prevention: closed system, bag below bladder above floor, no kinks, perineal hygiene, early removal, hand hygiene.
2. A nurse is preparing to give bed bath. What principle maintains client dignity?
A. Expose entire body
B. Provide privacy, drape, warm water, explain, allow participation, keep warm, respect
C. Cold water
D. No privacy
Answer: B
Rationale: Bed bath privacy draping warm water explain participation dignity.
3. A client has an order for sequential compression devices (SCDs). What should nurse do?
A. Never remove
B. No check needed
C. Leave off continuously
D. Apply properly, remove for skin assessment, check circulation, ensure sleeves not kinked, use while in bed, ambulation when off
Answer: D
Rationale: SCDs apply properly, remove for skin check circulation check kinks use while in bed.
4. A client is on strict intake and output. The client drank 4 oz juice, 8 oz coffee, and voided 350 mL. How should the nurse document intake?
A. 350 mL intake
B. No intake
C. 4 oz intake
D. 360 mL intake - 4 oz = 120 mL, 8 oz = 240 mL, total 360 mL intake, output 350 mL
Answer: D
Rationale: I&O; conversion 1 oz=30 mL, 4 oz=120, 8 oz=240 total 360 mL intake.
5. A nurse is caring for a client with impaired mobility. The client has a Braden Scale score of 12. Which intervention should the nurse prioritize
to prevent pressure injury?
A. Reposition every 2 hours, assess bony prominences, keep skin dry, use pressure-relieving mattress, nutrition consult - Braden 12 high risk
B. Only apply lotion
C. No intervention needed
D. Reposition every 4 hours
Answer: A
Rationale: Braden 12 high risk (<18 at risk, <16 moderate, <12 high). Priority q2h repositioning, skin assessment, moisture control, pressure relief,
nutrition.
6. A nurse is documenting using SOAPIE. What does it include?
A. Only subjective
B. Only objective
C. Subjective Objective Assessment Plan Intervention Evaluation - comprehensive charting
D. No plan
Answer: C
Rationale: SOAPIE Subjective Objective Assessment Plan Intervention Evaluation.
7. A nurse observes another nurse not performing hand hygiene before client contact. What is appropriate action?
A. No action
B. Yell publicly
C. Ignore
D. Speak privately, remind of policy, offer support, report if pattern continues via chain, advocate for client safety
Answer: D
Rationale: Peer not performing hand hygiene address privately remind policy support chain if pattern advocate safety.
8. A client reports pain 8/10. The nurse assesses OLDCARTS. What does this include?
A. No assessment
B. Only location
C. Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity - comprehensive pain assessment
D. Only severity
Answer: C
Rationale: OLDCARTS pain: Onset Location Duration Character Aggravating Alleviating Radiation Timing Severity.
9. A client is confused and attempting to get out of bed. What is nurse's priority?
, A. Assess cause confusion, reorient, ensure safety bed alarm low bed, nonslip, address needs pain toileting, consider sitter, last resort restraints with
order
B. Ignore
C. Apply restraints immediately
D. Leave alone
Answer: A
Rationale: Confused client safety priority assess cause reorient bed alarm low bed address needs sitter restraints last resort with order.
10. A client is on contact precautions for MRSA wound infection. What PPE should nurse wear?
A. Only mask
B. Gown and gloves, don before entering, doff before exiting, hand hygiene, private room or cohort
C. Only gloves
D. No PPE
Answer: B
Rationale: Contact precautions MRSA wound: gown and gloves don before entering doff before exiting hand hygiene private room.
11. A client has stage 2 pressure injury on sacrum. What is description?
A. Unstageable
B. Partial thickness skin loss with exposed dermis, blister or shallow crater pink-red moist, no slough, no fat visible
C. Intact skin redness
D. Full thickness with bone
Answer: B
Rationale: Stage2 partial thickness dermis exposed pink-red moist blister shallow crater no slough fat.
12. A nurse is documenting using SOAPIE. What does it include?
A. Only objective
B. No plan
C. Only subjective
D. Subjective Objective Assessment Plan Intervention Evaluation - comprehensive charting
Answer: D
Rationale: SOAPIE Subjective Objective Assessment Plan Intervention Evaluation.
13. A client has stage 2 pressure injury on sacrum. What is description?
A. Partial thickness skin loss with exposed dermis, blister or shallow crater pink-red moist, no slough, no fat visible
B. Full thickness with bone
C. Unstageable
D. Intact skin redness
Answer: A
Rationale: Stage2 partial thickness dermis exposed pink-red moist blister shallow crater no slough fat.
14. A nurse is preparing to give bed bath. What principle maintains client dignity?
A. Cold water
B. Expose entire body
C. Provide privacy, drape, warm water, explain, allow participation, keep warm, respect
D. No privacy
Answer: C
Rationale: Bed bath privacy draping warm water explain participation dignity.
15. A nurse is caring for client on droplet precautions for influenza. What is required?
A. Only gloves
B. Private room and N95
C. Private room or cohort, surgical mask within 3 feet, hand hygiene, limit transport, mask on client when transported
D. No mask
Answer: C
Rationale: Droplet influenza private room cohort surgical mask within 3ft hand hygiene mask on client transport.
16. A nurse is preparing to administer medications through a nasogastric tube. What is the correct action to ensure safe administration?
A. Check placement, flush 15-30mL water before and after each med, give meds separately, don't crush enteric-coated/ER, check compatibility
B. Mix all meds together
C. Crush all enteric-coated meds together
D. Give without flushing
Answer: A
Rationale: NG meds: check placement, flush before/after each med 15-30mL, separate administration, don't crush enteric-coated ER, check
compatibility.
17. A nurse is caring for a client with indwelling urinary catheter. What action prevents CAUTI?
A. No hygiene needed
B. Open system frequently
C. Maintain closed drainage system, bag below bladder above floor, no kinks, perineal hygiene, remove as soon as possible, hand hygiene
D. Leave bag on floor
, Answer: C
Rationale: CAUTI prevention: closed system, bag below bladder above floor, no kinks, perineal hygiene, early removal, hand hygiene.
18. A client has an order for sequential compression devices (SCDs). What should nurse do?
A. Never remove
B. Leave off continuously
C. Apply properly, remove for skin assessment, check circulation, ensure sleeves not kinked, use while in bed, ambulation when off
D. No check needed
Answer: C
Rationale: SCDs apply properly, remove for skin check circulation check kinks use while in bed.
19. A client is confused and attempting to get out of bed. What is nurse's priority?
A. Assess cause confusion, reorient, ensure safety bed alarm low bed, nonslip, address needs pain toileting, consider sitter, last resort restraints with
order
B. Apply restraints immediately
C. Ignore
D. Leave alone
Answer: A
Rationale: Confused client safety priority assess cause reorient bed alarm low bed address needs sitter restraints last resort with order.
20. What is correct order for donning PPE?
A. No order
B. Gloves first
C. Hand hygiene, gown, mask, goggles, gloves - donning
D. Mask first
Answer: C
Rationale: Donning: hand hygiene gown mask goggles gloves. Doffing: gloves goggles gown mask hand hygiene.
21. A client reports pain 8/10. The nurse assesses OLDCARTS. What does this include?
A. Only location
B. Only severity
C. Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity - comprehensive pain assessment
D. No assessment
Answer: C
Rationale: OLDCARTS pain: Onset Location Duration Character Aggravating Alleviating Radiation Timing Severity.
22. A client reports pain 8/10. The nurse assesses OLDCARTS. What does this include?
A. Only severity
B. Only location
C. Onset, Location, Duration, Character, Aggravating/Alleviating, Radiation, Timing, Severity - comprehensive pain assessment
D. No assessment
Answer: C
Rationale: OLDCARTS pain: Onset Location Duration Character Aggravating Alleviating Radiation Timing Severity.
23. A client needs assistance with ADLs. What does ADL include?
A. No ADL
B. Only work
C. Only medications
D. Activities of Daily Living - bathing, dressing, toileting, feeding, ambulation, grooming
Answer: D
Rationale: ADL bathing dressing toileting feeding ambulation grooming.
24. A client has stage 2 pressure injury on sacrum. What is description?
A. Intact skin redness
B. Unstageable
C. Partial thickness skin loss with exposed dermis, blister or shallow crater pink-red moist, no slough, no fat visible
D. Full thickness with bone
Answer: C
Rationale: Stage2 partial thickness dermis exposed pink-red moist blister shallow crater no slough fat.
25. A client is confused and attempting to get out of bed. What is nurse's priority?
A. Apply restraints immediately
B. Ignore
C. Leave alone
D. Assess cause confusion, reorient, ensure safety bed alarm low bed, nonslip, address needs pain toileting, consider sitter, last resort restraints with
order
Answer: D
Rationale: Confused client safety priority assess cause reorient bed alarm low bed address needs sitter restraints last resort with order.
26. A nurse is caring for a client who is NPO and receiving IV fluids. What indicates fluid overload?
