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HESI FUNDAMENTALS TEST BANK EXAM PREP 2026 QUESTIONS WITH
VERIFIED ANSWERS DETAILED RATIONALES GRADED A+
Part I: Nursing Process & Clinical Judgment (Questions 1–20)
1. A nurse is caring for a client who reports new-onset shortness of breath and has
an oxygen saturation of 88%. Which step of the nursing process should the nurse
implement first?
A. Formulate a nursing diagnosis of Ineffective Breathing Pattern.
B. Perform a focused respiratory assessment.
C. Administer a prescribed PRN bronchodilator.
D. Document the findings in the electronic health record.
Rationale: The first step of the nursing process is assessment. The nurse must
gather data (auscultate lungs, check respiratory rate and effort, etc.) before
making a diagnosis or intervening.
2. A nurse is using the SBAR communication tool to report a client’s condition to a
provider. Which component of SBAR includes the nurse’s recommendation for
what should happen next?
A. Situation
B. Background
C. Assessment
D. Recommendation
Rationale: In SBAR, the “R” stands for Recommendation. This is where the nurse
clearly states what they think is needed (e.g., “I recommend an order for a STAT
chest x-ray”).
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3. A nurse is developing a plan of care for a client with a stage 2 pressure injury.
Which goal is the most appropriate and measurable?
A. The client will remain free of infection.
B. The wound will show signs of healing.
C. The wound will decrease in size by 0.5 cm within one week.
D. The nurse will turn the client every 2 hours.
Rationale: A measurable goal must be specific, quantifiable, and time-bound.
“Decrease in size by 0.5 cm within one week” meets these criteria.
4. A client is admitted with a diagnosis of dehydration. Which nursing action is an
independent nursing intervention?
A. Administering a prescribed intravenous fluid bolus.
B. Offering oral fluids as tolerated.
C. Ordering a serum electrolyte panel.
D. Inserting a urinary catheter.
Rationale: Independent nursing interventions are actions the nurse can perform
without a provider’s order. Offering oral fluids, if not contraindicated, is an
independent function. The other options require a provider’s order.
5. A nurse is evaluating the effectiveness of a client’s pain management plan.
Which finding indicates that the plan has been successful?
A. The client’s respiratory rate is 10 breaths per minute.
B. The client reports a pain level of 2 on a 0–10 scale.
C. The client is sleeping and difficult to arouse.
D. The client presses the call light for pain medication.
Rationale: The most reliable indicator of pain is the client’s self-report. A
decreased pain score indicates effectiveness. A low respiratory rate or over-
sedation may indicate adverse effects.
6. A nurse is prioritizing care for a group of clients. Which client should the nurse
see first?
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A. A client requesting a PRN sleep aid.
B. A client who needs a dressing change.
C. A client reporting sudden, severe chest pain.
D. A client with a scheduled blood glucose check.
Rationale: Using the ABCs (Airway, Breathing, Circulation) or Maslow’s hierarchy, a
client with sudden, severe chest pain is the highest priority, as it may indicate a
life-threatening event like a myocardial infarction.
7. A nurse is collecting subjective data from a client. Which of the following is an
example of subjective data?
A. The client’s blood pressure is 150/90 mm Hg.
B. The client’s lung sounds are clear bilaterally.
C. The client states, “I feel like I have a fever.”
D. The client has a 3 cm reddened area on the sacrum.
Rationale: Subjective data are the client’s perceptions and feelings, which cannot
be directly observed or measured by the nurse. Objective data are measurable
and observable (vital signs, lung sounds, skin findings).
8. A nurse is planning care for a client with a nursing diagnosis of Risk for Falls.
Which intervention is the highest priority?
A. Providing the client with a walker.
B. Ensuring the call light is within reach.
C. Educating the client on the use of the bedpan.
D. Placing the bed in the highest position.
Rationale: Ensuring the call light is within reach is a critical safety intervention to
prevent falls, allowing the client to summon help without attempting to ambulate
unsafely. The bed should be in the lowest position.
9. A nurse is reviewing a new medication order for a client with a new diagnosis of
hypertension. Which action demonstrates the “Planning” phase of the nursing
process?
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A. Taking the client’s blood pressure.
B. Administering the antihypertensive medication.
C. Establishing a goal that the client’s blood pressure will be <140/90 mm Hg
within 24 hours.
D. Determining that the client’s blood pressure has decreased.
Rationale: Planning involves setting client-centered, measurable goals and
outcomes, and determining interventions to achieve them.
10. A nurse is caring for a client who is scheduled for surgery. Which action is part
of the “Implementation” phase of the nursing process?
A. Asking the client about their allergies.
B. Formulating the nursing diagnosis of Anxiety.
C. Performing a pre-operative teaching session.
D. Revising the care plan because the client’s anxiety has increased.
Rationale: Implementation is the action phase where the nurse carries out the
planned interventions, such as teaching. Assessment (asking about allergies),
diagnosis (formulating a diagnosis), and evaluation (revising the plan) are separate
steps.
11. A nurse is using the Clinical Judgment Measurement Model to address a
client’s problem. Which step follows “Generate Solutions”?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Rationale: The NGN clinical judgment model sequence is: Recognize Cues →
Analyze Cues → Prioritize Hypotheses → Generate Solutions → Take Action →
Evaluate Outcomes.
12. A nurse is analyzing cues from a client’s assessment. The client has a heart rate
of 110 bpm, a blood pressure of 90/60 mm Hg, and cool, clammy skin. Which
hypothesis should the nurse prioritize?
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HESI FUNDAMENTALS TEST BANK EXAM PREP 2026 QUESTIONS WITH
VERIFIED ANSWERS DETAILED RATIONALES GRADED A+
Part I: Nursing Process & Clinical Judgment (Questions 1–20)
1. A nurse is caring for a client who reports new-onset shortness of breath and has
an oxygen saturation of 88%. Which step of the nursing process should the nurse
implement first?
A. Formulate a nursing diagnosis of Ineffective Breathing Pattern.
B. Perform a focused respiratory assessment.
C. Administer a prescribed PRN bronchodilator.
D. Document the findings in the electronic health record.
Rationale: The first step of the nursing process is assessment. The nurse must
gather data (auscultate lungs, check respiratory rate and effort, etc.) before
making a diagnosis or intervening.
2. A nurse is using the SBAR communication tool to report a client’s condition to a
provider. Which component of SBAR includes the nurse’s recommendation for
what should happen next?
A. Situation
B. Background
C. Assessment
D. Recommendation
Rationale: In SBAR, the “R” stands for Recommendation. This is where the nurse
clearly states what they think is needed (e.g., “I recommend an order for a STAT
chest x-ray”).
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,Page 2 of 64
3. A nurse is developing a plan of care for a client with a stage 2 pressure injury.
Which goal is the most appropriate and measurable?
A. The client will remain free of infection.
B. The wound will show signs of healing.
C. The wound will decrease in size by 0.5 cm within one week.
D. The nurse will turn the client every 2 hours.
Rationale: A measurable goal must be specific, quantifiable, and time-bound.
“Decrease in size by 0.5 cm within one week” meets these criteria.
4. A client is admitted with a diagnosis of dehydration. Which nursing action is an
independent nursing intervention?
A. Administering a prescribed intravenous fluid bolus.
B. Offering oral fluids as tolerated.
C. Ordering a serum electrolyte panel.
D. Inserting a urinary catheter.
Rationale: Independent nursing interventions are actions the nurse can perform
without a provider’s order. Offering oral fluids, if not contraindicated, is an
independent function. The other options require a provider’s order.
5. A nurse is evaluating the effectiveness of a client’s pain management plan.
Which finding indicates that the plan has been successful?
A. The client’s respiratory rate is 10 breaths per minute.
B. The client reports a pain level of 2 on a 0–10 scale.
C. The client is sleeping and difficult to arouse.
D. The client presses the call light for pain medication.
Rationale: The most reliable indicator of pain is the client’s self-report. A
decreased pain score indicates effectiveness. A low respiratory rate or over-
sedation may indicate adverse effects.
6. A nurse is prioritizing care for a group of clients. Which client should the nurse
see first?
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A. A client requesting a PRN sleep aid.
B. A client who needs a dressing change.
C. A client reporting sudden, severe chest pain.
D. A client with a scheduled blood glucose check.
Rationale: Using the ABCs (Airway, Breathing, Circulation) or Maslow’s hierarchy, a
client with sudden, severe chest pain is the highest priority, as it may indicate a
life-threatening event like a myocardial infarction.
7. A nurse is collecting subjective data from a client. Which of the following is an
example of subjective data?
A. The client’s blood pressure is 150/90 mm Hg.
B. The client’s lung sounds are clear bilaterally.
C. The client states, “I feel like I have a fever.”
D. The client has a 3 cm reddened area on the sacrum.
Rationale: Subjective data are the client’s perceptions and feelings, which cannot
be directly observed or measured by the nurse. Objective data are measurable
and observable (vital signs, lung sounds, skin findings).
8. A nurse is planning care for a client with a nursing diagnosis of Risk for Falls.
Which intervention is the highest priority?
A. Providing the client with a walker.
B. Ensuring the call light is within reach.
C. Educating the client on the use of the bedpan.
D. Placing the bed in the highest position.
Rationale: Ensuring the call light is within reach is a critical safety intervention to
prevent falls, allowing the client to summon help without attempting to ambulate
unsafely. The bed should be in the lowest position.
9. A nurse is reviewing a new medication order for a client with a new diagnosis of
hypertension. Which action demonstrates the “Planning” phase of the nursing
process?
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A. Taking the client’s blood pressure.
B. Administering the antihypertensive medication.
C. Establishing a goal that the client’s blood pressure will be <140/90 mm Hg
within 24 hours.
D. Determining that the client’s blood pressure has decreased.
Rationale: Planning involves setting client-centered, measurable goals and
outcomes, and determining interventions to achieve them.
10. A nurse is caring for a client who is scheduled for surgery. Which action is part
of the “Implementation” phase of the nursing process?
A. Asking the client about their allergies.
B. Formulating the nursing diagnosis of Anxiety.
C. Performing a pre-operative teaching session.
D. Revising the care plan because the client’s anxiety has increased.
Rationale: Implementation is the action phase where the nurse carries out the
planned interventions, such as teaching. Assessment (asking about allergies),
diagnosis (formulating a diagnosis), and evaluation (revising the plan) are separate
steps.
11. A nurse is using the Clinical Judgment Measurement Model to address a
client’s problem. Which step follows “Generate Solutions”?
A. Recognize Cues
B. Analyze Cues
C. Take Action
D. Evaluate Outcomes
Rationale: The NGN clinical judgment model sequence is: Recognize Cues →
Analyze Cues → Prioritize Hypotheses → Generate Solutions → Take Action →
Evaluate Outcomes.
12. A nurse is analyzing cues from a client’s assessment. The client has a heart rate
of 110 bpm, a blood pressure of 90/60 mm Hg, and cool, clammy skin. Which
hypothesis should the nurse prioritize?
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