Additional HESI Fundamentals
Exam Questions
Practice Questions with Verified
Answers & Rationales
1. What is the rationale for using the nursing process in
planning care for clients?
A. As a scientific process to identify nursing diagnoses of a clients'
healthcare problems.
B. To establish nursing theory that incorporates the biopsychosocial
nature of humans.
C. As a tool to organize thinking and clinical decision making about
clients' healthcare needs.
D. To promote the management of client care in collaboration with
other healthcare professionals.
Answer: C. As a tool to organize thinking and clinical
decision making about clients' healthcare needs.
Rationale: The nursing process is a problem-solving approach that
provides an organized, systematic, decision-making process to
effectively address the client's needs and problems. The nursing
process includes an organized framework using knowledge,
judgments, and actions by the nurse as the client's plan of care is
determined, and encompasses assessment, analysis, planning,
implementation, and evaluation.
2. What activity should the nurse use in the evaluation
phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been
alleviated.
D. Examine the effectiveness of nursing interventions toward
meeting client outcomes.
Answer: D. Examine the effectiveness of nursing
interventions toward meeting client outcomes.
Rationale: In the nursing process, the evaluation component
examines the effectiveness of nursing interventions in achieving
1
,client outcomes (D). (A) is an evaluation of client satisfaction, not
outcomes. (B) is a written record of the plan of care. Although (C)
may occur when client outcomes are achieved, evaluation is best
determined by attainment of measurable client outcomes.
3. Which statement is an example of a correctly written
nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test
results.
Answer: D. Ineffective coping related to response to positive
biopsy test results.
Rationale: The first part of the nursing diagnosis statement is the
diagnostic label and is followed by related to the cause, which
should direct the nurse to the appropriate interventions. (D) best fits
this criteria. (A and B) contain a medical diagnosis. (C) includes an
observance of the cause, but (D) focuses on the client's response,
which the nurse can provide support, reflection, and dialogue.
4. What action by the nurse demonstrates culturally
sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and
cultural folk remedies.
D. Applies knowledge of a cultural group unless a client embraces
Western customs.
Answer: A. Asks permission before touching a client.
Rationale: Physical contact, such as touching the head, in some
cultures is a sign of respect, whereas in others, it is strictly
forbidden. So asking permission before touching a client (A)
demonstrates culturally sensitive care. (B, C, and D) do not
demonstrate cultural awareness.
5. A nurse is becoming increasingly frustrated by the family
members' efforts to participate in the care of a hospitalized
2
,client. What action should the nurse implement to cope with
these feelings of frustration?
A. Suggest that other cultural practices be substituted by the family
members.
B. Examine one's own culturally based values, beliefs, attitudes, and
practices.
C. Explain to the family that multiple visitors are exhausting to the
client.
D. Allow the situation to continue until a family member's action
may harm the client.
Answer: B. Examine one's own culturally based values,
beliefs, attitudes, and practices.
Rationale: Acknowledging a client's beliefs and customs related to
sickness and health care are valuable components in the plan of
care that prevents conflict between the goals of nursing and the
client's cultural practices. Cultural sensitivity begins with examining
one's own cultural values (B) to compare, recognize, and
acknowledge cultural bias. (A and C) do not consider the family's
needs to care for the client and are not the best ways to cope with
the nurse's frustration. Although (D) may be an option, examining
one's cultural differences allows the nurse to cope, empathize, and
implement culturally specific interventions pertaining to the needs
of the client and the family.
6. Which technique is most important for the nurse to
implement when performing a physical assessment?
A. A head-to-toe approach.
B. The medical systems model.
C. A consistent, systematic approach.
D. An approach related to a nursing model.
Answer: C. A consistent, systematic approach.
Rationale: The most important factor in performing a physical
assessment is following a consistent and systematic technique (C)
each time an assessment is performed to minimize variation in
sequence which may increase the likelihood of omitting a step or
exam of an isolated area. The method of completing a physical
assessment (A, B, and D) may be at the discretion of the examiner,
but a consistent sequence by the examiner provides a reliable
method to ensure thorough review of the clients' history,
complaints, or body systems.
3
, 7. A 73-year-old Hispanic client is seen at the community
health clinic with a history of protein malnutrition. What
information should the nurse obtain first?
A. Amount of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client.
Answer: B. Foods and liquids consumed during the past 24
hours.
Rationale: A client's dietary habits should be determined first by
the client's dietary recall (B) before suggesting protein sources or
supplements (A and C) as options in the client's diet. Although
grains and legumes (D) contain incomplete proteins that reduces
the essential amino acid pools inside the cells, the client's cultural
preferences should be elicited after confirming the client's dietary
history.
8. The nurse formulates the nursing diagnosis of,
"Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding
supports this nursing diagnosis?
A. Does not check capillary blood glucose as directed.
B. Occasionally forgets to take daily prescribed medication.
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in
health.
Answer: D. Eats anything and does not think diet makes a
difference in health.
Rationale: The nursing diagnosis of ineffective health maintenance
refers to an inability to identify, manage, and/or seek out help to
maintain health, and is best exemplified in the client belief or
understanding about diet and health maintenance (D). (A) indicates
noncompliance with an action to be done in the management of
diabetes. (B) represents inattentiveness. (C) reflects knowledge
deficit.
9. Which statement correctly identifies a written learning
objective for a client with peripheral vascular disease?
A. The nurse will provide client instruction for daily foot care.
B. The client will demonstrate proper trimming toenail technique.
4
Exam Questions
Practice Questions with Verified
Answers & Rationales
1. What is the rationale for using the nursing process in
planning care for clients?
A. As a scientific process to identify nursing diagnoses of a clients'
healthcare problems.
B. To establish nursing theory that incorporates the biopsychosocial
nature of humans.
C. As a tool to organize thinking and clinical decision making about
clients' healthcare needs.
D. To promote the management of client care in collaboration with
other healthcare professionals.
Answer: C. As a tool to organize thinking and clinical
decision making about clients' healthcare needs.
Rationale: The nursing process is a problem-solving approach that
provides an organized, systematic, decision-making process to
effectively address the client's needs and problems. The nursing
process includes an organized framework using knowledge,
judgments, and actions by the nurse as the client's plan of care is
determined, and encompasses assessment, analysis, planning,
implementation, and evaluation.
2. What activity should the nurse use in the evaluation
phase of the nursing process?
A. Ask a client to evaluate the nursing care provided.
B. Document the nursing care plan in the progress notes.
C. Determine whether a client's health problems have been
alleviated.
D. Examine the effectiveness of nursing interventions toward
meeting client outcomes.
Answer: D. Examine the effectiveness of nursing
interventions toward meeting client outcomes.
Rationale: In the nursing process, the evaluation component
examines the effectiveness of nursing interventions in achieving
1
,client outcomes (D). (A) is an evaluation of client satisfaction, not
outcomes. (B) is a written record of the plan of care. Although (C)
may occur when client outcomes are achieved, evaluation is best
determined by attainment of measurable client outcomes.
3. Which statement is an example of a correctly written
nursing diagnosis statement?
A. Altered tissue perfusion related to congestive heart failure.
B. Altered urinary elimination related to urinary tract infection.
C. Risk for impaired tissue integrity related to client's refusal to turn.
D. Ineffective coping related to response to positive biopsy test
results.
Answer: D. Ineffective coping related to response to positive
biopsy test results.
Rationale: The first part of the nursing diagnosis statement is the
diagnostic label and is followed by related to the cause, which
should direct the nurse to the appropriate interventions. (D) best fits
this criteria. (A and B) contain a medical diagnosis. (C) includes an
observance of the cause, but (D) focuses on the client's response,
which the nurse can provide support, reflection, and dialogue.
4. What action by the nurse demonstrates culturally
sensitive care?
A. Asks permission before touching a client.
B. Avoids questions about male-female relationships.
C. Explains the differences between Western medical care and
cultural folk remedies.
D. Applies knowledge of a cultural group unless a client embraces
Western customs.
Answer: A. Asks permission before touching a client.
Rationale: Physical contact, such as touching the head, in some
cultures is a sign of respect, whereas in others, it is strictly
forbidden. So asking permission before touching a client (A)
demonstrates culturally sensitive care. (B, C, and D) do not
demonstrate cultural awareness.
5. A nurse is becoming increasingly frustrated by the family
members' efforts to participate in the care of a hospitalized
2
,client. What action should the nurse implement to cope with
these feelings of frustration?
A. Suggest that other cultural practices be substituted by the family
members.
B. Examine one's own culturally based values, beliefs, attitudes, and
practices.
C. Explain to the family that multiple visitors are exhausting to the
client.
D. Allow the situation to continue until a family member's action
may harm the client.
Answer: B. Examine one's own culturally based values,
beliefs, attitudes, and practices.
Rationale: Acknowledging a client's beliefs and customs related to
sickness and health care are valuable components in the plan of
care that prevents conflict between the goals of nursing and the
client's cultural practices. Cultural sensitivity begins with examining
one's own cultural values (B) to compare, recognize, and
acknowledge cultural bias. (A and C) do not consider the family's
needs to care for the client and are not the best ways to cope with
the nurse's frustration. Although (D) may be an option, examining
one's cultural differences allows the nurse to cope, empathize, and
implement culturally specific interventions pertaining to the needs
of the client and the family.
6. Which technique is most important for the nurse to
implement when performing a physical assessment?
A. A head-to-toe approach.
B. The medical systems model.
C. A consistent, systematic approach.
D. An approach related to a nursing model.
Answer: C. A consistent, systematic approach.
Rationale: The most important factor in performing a physical
assessment is following a consistent and systematic technique (C)
each time an assessment is performed to minimize variation in
sequence which may increase the likelihood of omitting a step or
exam of an isolated area. The method of completing a physical
assessment (A, B, and D) may be at the discretion of the examiner,
but a consistent sequence by the examiner provides a reliable
method to ensure thorough review of the clients' history,
complaints, or body systems.
3
, 7. A 73-year-old Hispanic client is seen at the community
health clinic with a history of protein malnutrition. What
information should the nurse obtain first?
A. Amount of liquid protein supplements consumed daily.
B. Foods and liquids consumed during the past 24 hours.
C. Usual weekly intake of milk products and red meats.
D. Grains and legume combinations used by the client.
Answer: B. Foods and liquids consumed during the past 24
hours.
Rationale: A client's dietary habits should be determined first by
the client's dietary recall (B) before suggesting protein sources or
supplements (A and C) as options in the client's diet. Although
grains and legumes (D) contain incomplete proteins that reduces
the essential amino acid pools inside the cells, the client's cultural
preferences should be elicited after confirming the client's dietary
history.
8. The nurse formulates the nursing diagnosis of,
"Ineffective health maintenance related to lack of
motivation" for a client with Type 2 diabetes. Which finding
supports this nursing diagnosis?
A. Does not check capillary blood glucose as directed.
B. Occasionally forgets to take daily prescribed medication.
C. Cannot identify signs or symptoms of high and low blood glucose.
D. Eats anything and does not think diet makes a difference in
health.
Answer: D. Eats anything and does not think diet makes a
difference in health.
Rationale: The nursing diagnosis of ineffective health maintenance
refers to an inability to identify, manage, and/or seek out help to
maintain health, and is best exemplified in the client belief or
understanding about diet and health maintenance (D). (A) indicates
noncompliance with an action to be done in the management of
diabetes. (B) represents inattentiveness. (C) reflects knowledge
deficit.
9. Which statement correctly identifies a written learning
objective for a client with peripheral vascular disease?
A. The nurse will provide client instruction for daily foot care.
B. The client will demonstrate proper trimming toenail technique.
4
