HESI FUNDAMENTALS PRACTICE EXAM 2025/2026
WITH QUESTIONS AND VERIFIED ANSWERS
When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - ANS-A. Loosen the right wrist restraint.
(The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures saturation of hemoglobin with oxygen and is not indicated in situations where
the cyanosis is related to mechanical compression-- the restraints.)
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse
is at greatest risk for a malpractice judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. - ANS-
C. The nurse who transferred the client to the chair when the fall occurred.
(The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury.
The hip fracture is the actual injury and the standard of care was "frequent monitoring."
(C) implies the duty was owed and the injury occurred while the nurse was in charge of
the client's care. There is no evidence of negligence in (A, B, and D). )
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - ANS-B.
Reassess the client's blood pressure using a larger cuff.
(The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).)
The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/ 30
units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
,infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration
set. The nurse plans to set the flow rate at how many gtt/min? - ANS-83 gtt/min
Which assessment data provides the most accurate determination of proper placement
of a nasogastric tube? - ANS-Examining a chest x-ray obtained after the tubing was
inserted
Three days following a surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the nurse that it is much bigger than he expected.
What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in
time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. - ANS-B. Instruct the client that the stoma will become smaller when the
initial swelling diminishes (Postoperative swelling causes enlargement of the stoma.
The nurse can teach the client that the stoma will become smaller when swelling is
diminished (B). This will help reduce the client's anxiety and promote acceptance of the
colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and
may be taken after the nurse provides pertinent teaching. The client is not yet
demonstrating readiness to learn colostomy care. (D)
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - ANS-B. Reposition
the client on her side. (The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive intervention
(B) should be attempted first, followed by (A and C), unless either of these interventions
is contraindicated. If these measures are unsuccessful, the client may require an
antiemetic (D))
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. He reports that he had a bad bout of severe coughing
a few minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
, D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - ANS-
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
A male client tells the nurse that he does not know where he is or what year it is. What
data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - ANS-D. is disoriented to place and time (The client
is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is
able to express himself without difficulty (B), and does not demonstrate diminished
attention span. (C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast.
What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - ANS-A.
Commend the client for selecting a high biologic value protein. (Foods such as eggs
and milk (A) are high biologic proteins which are allowed because they are complete
proteins and supply the essential amino acids that are necessary for growth and cell
repair. Orange juice is rich in potassium and should not be encouraged. The client has
made a good diet choice so (D) is not necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to realize
that the center of gravity for an elderly person is the-- - ANS-Upper torso (The center of
gravity for adults is the hips. However, as the person grows older, a stooped posture is
common because of the changes from osteoporosis and normal bone degeneration,
and the knees, hips, and elbows flex. This stooped posture results in the upper torso
becoming the center of gravity for older persons.)
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - ANS-B. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests
itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for
confusion.)
The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first?
WITH QUESTIONS AND VERIFIED ANSWERS
When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. - ANS-A. Loosen the right wrist restraint.
(The priority nursing action is to restore circulation by loosening the restraint (A),
because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also
important nursing interventions, but do not have the priority of (A). Pulse oximetry (B)
measures saturation of hemoglobin with oxygen and is not indicated in situations where
the cyanosis is related to mechanical compression-- the restraints.)
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse
is at greatest risk for a malpractice judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at the time of the fall.
C. The nurse who transferred the client to the chair when the fall occurred.
D. The charge nurse who completed rounds 30 minutes before the fall occurred. - ANS-
C. The nurse who transferred the client to the chair when the fall occurred.
(The four elements of malpractice are: breach of duty owed, failure to adhere to the
recognized standard of care, direct causation of injury, and evidence of actual injury.
The hip fracture is the actual injury and the standard of care was "frequent monitoring."
(C) implies the duty was owed and the injury occurred while the nurse was in charge of
the client's care. There is no evidence of negligence in (A, B, and D). )
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - ANS-B.
Reassess the client's blood pressure using a larger cuff.
(The most important action is to ensure that an accurate BP reading is obtained. The
nurse should reassess the BP with the correct size cuff (B). Reassessment should not
be postponed (A). Though (C and D) are likely indicated, these actions do not have the
priority of (B).)
The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/ 30
units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
,infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration
set. The nurse plans to set the flow rate at how many gtt/min? - ANS-83 gtt/min
Which assessment data provides the most accurate determination of proper placement
of a nasogastric tube? - ANS-Examining a chest x-ray obtained after the tubing was
inserted
Three days following a surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the nurse that it is much bigger than he expected.
What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in
time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure. - ANS-B. Instruct the client that the stoma will become smaller when the
initial swelling diminishes (Postoperative swelling causes enlargement of the stoma.
The nurse can teach the client that the stoma will become smaller when swelling is
diminished (B). This will help reduce the client's anxiety and promote acceptance of the
colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and
may be taken after the nurse provides pertinent teaching. The client is not yet
demonstrating readiness to learn colostomy care. (D)
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - ANS-B. Reposition
the client on her side. (The immediate priority is to determine if the tube is functioning
correctly, which would then relieve the client's nausea. The least invasive intervention
(B) should be attempted first, followed by (A and C), unless either of these interventions
is contraindicated. If these measures are unsuccessful, the client may require an
antiemetic (D))
A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. He reports that he had a bad bout of severe coughing
a few minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
, D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. - ANS-
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
A male client tells the nurse that he does not know where he is or what year it is. What
data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - ANS-D. is disoriented to place and time (The client
is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is
able to express himself without difficulty (B), and does not demonstrate diminished
attention span. (C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast.
What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - ANS-A.
Commend the client for selecting a high biologic value protein. (Foods such as eggs
and milk (A) are high biologic proteins which are allowed because they are complete
proteins and supply the essential amino acids that are necessary for growth and cell
repair. Orange juice is rich in potassium and should not be encouraged. The client has
made a good diet choice so (D) is not necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to realize
that the center of gravity for an elderly person is the-- - ANS-Upper torso (The center of
gravity for adults is the hips. However, as the person grows older, a stooped posture is
common because of the changes from osteoporosis and normal bone degeneration,
and the knees, hips, and elbows flex. This stooped posture results in the upper torso
becoming the center of gravity for older persons.)
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - ANS-B. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests
itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for
confusion.)
The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first?
