HESI-RN Fundamentals BEST STUDYING
MATERIAL WITH VERIFIED ANSWERS
LATEST VERSION UPDATE 2024-2025
WITH 100+ QUESTIONS
The nurse is preparing to change the bed of a client who is non-responsive, and
receiving continuous enteral tube feedings. What step must the nurse take prior to
changing the bed?
A.
Stop the feeding for 15 minutes prior to changing the bed.
B.
Obtain extra linens to absorb any feeding that leaks out of the mouth.
C.
Ask another nurse to help with changing the bed.
D.
Ask the client's spouse to leave the room during the bed change.
- CORRECT ANS-A
Rationale: This client is at risk for aspiration during the bed change as the head of the
bed must be lowered. Stopping the feeding will help decompress the stomach and
decrease the risk. The client should not be leaking fluid out of the mouth. Check the
feeding for residual. If the feeding is not moving out of the stomach, notify the
healthcare provider. Assistance with changing a bed is nice for the nurse, but is not
imperative for the client's safety. The spouse does not need to leave the room.
The nurse is at a teen event. Which teen's statement would cause the nurse to input
some safety tips? (Select all that apply.)
A.
"My boyfriend and I fool around on occasion, but he never comes when he is inside
me."
B.
"I hang around with my friends after the games, like football and baseball."
C.
"I work until 10:00 pm at a local fast-food restaurant."
D.
"I never use my seatbelt while I am driving. I hate the way it feels."
E.
"We often go and play beach volleyball when it is nice out."
- CORRECT ANS-A, D
Rationale: Sexual exploration is not uncommon as a teen. However, pregnancy can
occur with ejaculation on the perineal area. Accidents are the leading cause of death in
,the teen years and seatbelt use must be encouraged at all times. The remaining
statements demonstrate normal growth and development for the teen years.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain
of infection?
A.
Mode of transmission
B.
Portal of entry
C.
Reservoir
D.
Portal of exit
- CORRECT ANS-A
Rationale: The contaminated gloves serve as the mode of transmission from the portal
of exit of the reservoir to a portal of entry.
The health care provider diagnoses metastatic cancer and recommends a gastrostomy
for an elderly client in stable condition. The client's adult child is concerned and states to
the nurse, "I don't think my parent 'can handle' the cancer diagnosis." What information
will guide the nurse's response?
A.
The family can provide the consent required in this situation because the older adult is
in no condition to make such decisions.
B.
Because the client is mentally incompetent, the adult child has the right to waive
informed consent for the parent.
C.
The court will allow the health care provider to make the decision to withhold informed
consent under therapeutic privilege.
D.
If informed consent is withheld from a client, health care providers could be found guilty
of negligence.
- CORRECT ANS-D
Rationale: Health care providers may be found guilty of negligence, specifically assault
and battery, if they carry out a treatment without the client's consent. The client's
condition is stable, so option A is not a valid rationale. Advanced age does not
automatically authorize the son to make all decisions for his mother, and there is no
evidence that the client is mentally incompetent. Although option C may have been
upheld in the past, when paternalistic medical practice was common, today's courts are
unlikely to accept it.
After a needle stick occurs while removing the cap from a sterile needle, which action
should the nurse take next?
A.
Complete an incident report.
, B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately.
- CORRECT ANS-B
Rationale: After a needle stick, the needle is considered used, so the nurse should
discard it and select another needle. Because the needle was sterile when the nurse
was stuck and the needle was not in contact with any other person's body fluids, the
nurse does not need to complete an incident report or notify the occupational health
nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards
for safe practice and infection control.
An 89-year-old client is admitted to the rehabilitation unit after a hip fracture. When
reviewing the client's pre-fracture routine the client states, "I usually get up around 0800
and have breakfast by 0900; I say my daily prayers between 1000 and 1030. I like lunch
around 1300; then a nap from 1400 to 1600. I generally eat supper around 1900." What
is the nurse's best response to the client's schedule?
A.
"We can try our best to work around your schedule."
B.
"Your physical therapy is scheduled for 1500 to 1600."
C.
"You will have to get your own supper if you want to eat that late."
D.
"Is there any way you could say your prayers between 1230 and 1300?"
- CORRECT ANS-D
Rationale:The elderly have a routine that generally fits around their sleep-wake cycle, or
their circadian rhythm. The flexibility is around prayer time, since it is during the wake
time. If the rehabilitation therapy can be scheduled in the am, that is generally the time
when they have more energy. Trying the best, does not place the client's sleep-wake
schedule as a priority. While supper on the rehab unit may be before 1900,
arrangements can be made to deliver a tray later, or keep a tray warm
The nurse determines that a postoperative client's respiratory rate has increased from
18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing
action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea.
, - CORRECT ANS-D
Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause
tachypnea (increased respiratory rate). Encouraging the client to increase ambulation
when the respiratory rate is rising above normal limits puts the client at risk for further
oxygen desaturation. Option B can increase the client's carbon metabolism, so an
alternative source of energy, such as Pulmocare liquid supplement, should be offered
instead. Option C could increase respiratory congestion in a client with a poorly
functioning cardiopulmonary system, placing the client at risk of fluid overload
Urinary catheterization is prescribed for a postoperative female client who has been
unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the
tubing. Which action will the nurse take next?
A.
Clamp the catheter and recheck it in 60 minutes.
B.
Pull the catheter back 3 inches and redirect upward.
C.
Leave the catheter in place and reattempt with another catheter.
D.
Notify the health care provider of a possible obstruction.
- CORRECT ANS-C
Rationale: It is likely that the first catheter is in the vagina, rather than the bladder.
Leaving the first catheter in place will help locate the meatus when attempting the
second catheterization. The client should have at least 240 mL of urine after 8 hours.
Option A does not resolve the problem. Option B will not change the location of the
catheter unless it is completely removed, in which case a new catheter must be used.
There is no evidence of a urinary tract obstruction if the catheter could be easily
inserted.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A.
White blood cell count
B.
Albumin
C.
Calcium
D.
Sodium
- CORRECT ANS-D
Rationale: Monitoring serum sodium levels for hyponatremia is indicated during
prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or
C are not typically associated with prolonged NG suctioning.
MATERIAL WITH VERIFIED ANSWERS
LATEST VERSION UPDATE 2024-2025
WITH 100+ QUESTIONS
The nurse is preparing to change the bed of a client who is non-responsive, and
receiving continuous enteral tube feedings. What step must the nurse take prior to
changing the bed?
A.
Stop the feeding for 15 minutes prior to changing the bed.
B.
Obtain extra linens to absorb any feeding that leaks out of the mouth.
C.
Ask another nurse to help with changing the bed.
D.
Ask the client's spouse to leave the room during the bed change.
- CORRECT ANS-A
Rationale: This client is at risk for aspiration during the bed change as the head of the
bed must be lowered. Stopping the feeding will help decompress the stomach and
decrease the risk. The client should not be leaking fluid out of the mouth. Check the
feeding for residual. If the feeding is not moving out of the stomach, notify the
healthcare provider. Assistance with changing a bed is nice for the nurse, but is not
imperative for the client's safety. The spouse does not need to leave the room.
The nurse is at a teen event. Which teen's statement would cause the nurse to input
some safety tips? (Select all that apply.)
A.
"My boyfriend and I fool around on occasion, but he never comes when he is inside
me."
B.
"I hang around with my friends after the games, like football and baseball."
C.
"I work until 10:00 pm at a local fast-food restaurant."
D.
"I never use my seatbelt while I am driving. I hate the way it feels."
E.
"We often go and play beach volleyball when it is nice out."
- CORRECT ANS-A, D
Rationale: Sexual exploration is not uncommon as a teen. However, pregnancy can
occur with ejaculation on the perineal area. Accidents are the leading cause of death in
,the teen years and seatbelt use must be encouraged at all times. The remaining
statements demonstrate normal growth and development for the teen years.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain
of infection?
A.
Mode of transmission
B.
Portal of entry
C.
Reservoir
D.
Portal of exit
- CORRECT ANS-A
Rationale: The contaminated gloves serve as the mode of transmission from the portal
of exit of the reservoir to a portal of entry.
The health care provider diagnoses metastatic cancer and recommends a gastrostomy
for an elderly client in stable condition. The client's adult child is concerned and states to
the nurse, "I don't think my parent 'can handle' the cancer diagnosis." What information
will guide the nurse's response?
A.
The family can provide the consent required in this situation because the older adult is
in no condition to make such decisions.
B.
Because the client is mentally incompetent, the adult child has the right to waive
informed consent for the parent.
C.
The court will allow the health care provider to make the decision to withhold informed
consent under therapeutic privilege.
D.
If informed consent is withheld from a client, health care providers could be found guilty
of negligence.
- CORRECT ANS-D
Rationale: Health care providers may be found guilty of negligence, specifically assault
and battery, if they carry out a treatment without the client's consent. The client's
condition is stable, so option A is not a valid rationale. Advanced age does not
automatically authorize the son to make all decisions for his mother, and there is no
evidence that the client is mentally incompetent. Although option C may have been
upheld in the past, when paternalistic medical practice was common, today's courts are
unlikely to accept it.
After a needle stick occurs while removing the cap from a sterile needle, which action
should the nurse take next?
A.
Complete an incident report.
, B.
Select another sterile needle.
C.
Disinfect the needle with an alcohol swab.
D.
Notify the supervisor of the department immediately.
- CORRECT ANS-B
Rationale: After a needle stick, the needle is considered used, so the nurse should
discard it and select another needle. Because the needle was sterile when the nurse
was stuck and the needle was not in contact with any other person's body fluids, the
nurse does not need to complete an incident report or notify the occupational health
nurse. Disinfecting a needle with an alcohol swab is not in accordance with standards
for safe practice and infection control.
An 89-year-old client is admitted to the rehabilitation unit after a hip fracture. When
reviewing the client's pre-fracture routine the client states, "I usually get up around 0800
and have breakfast by 0900; I say my daily prayers between 1000 and 1030. I like lunch
around 1300; then a nap from 1400 to 1600. I generally eat supper around 1900." What
is the nurse's best response to the client's schedule?
A.
"We can try our best to work around your schedule."
B.
"Your physical therapy is scheduled for 1500 to 1600."
C.
"You will have to get your own supper if you want to eat that late."
D.
"Is there any way you could say your prayers between 1230 and 1300?"
- CORRECT ANS-D
Rationale:The elderly have a routine that generally fits around their sleep-wake cycle, or
their circadian rhythm. The flexibility is around prayer time, since it is during the wake
time. If the rehabilitation therapy can be scheduled in the am, that is generally the time
when they have more energy. Trying the best, does not place the client's sleep-wake
schedule as a priority. While supper on the rehab unit may be before 1900,
arrangements can be made to deliver a tray later, or keep a tray warm
The nurse determines that a postoperative client's respiratory rate has increased from
18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing
action?
A.
Encourage the client to increase ambulation in the room.
B.
Offer the client a high-carbohydrate snack for energy.
C.
Force fluids to thin the client's pulmonary secretions.
D.
Determine if pain is causing the client's tachypnea.
, - CORRECT ANS-D
Rationale: Pain, anxiety, and increasing fluid accumulation in the lungs can cause
tachypnea (increased respiratory rate). Encouraging the client to increase ambulation
when the respiratory rate is rising above normal limits puts the client at risk for further
oxygen desaturation. Option B can increase the client's carbon metabolism, so an
alternative source of energy, such as Pulmocare liquid supplement, should be offered
instead. Option C could increase respiratory congestion in a client with a poorly
functioning cardiopulmonary system, placing the client at risk of fluid overload
Urinary catheterization is prescribed for a postoperative female client who has been
unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the
tubing. Which action will the nurse take next?
A.
Clamp the catheter and recheck it in 60 minutes.
B.
Pull the catheter back 3 inches and redirect upward.
C.
Leave the catheter in place and reattempt with another catheter.
D.
Notify the health care provider of a possible obstruction.
- CORRECT ANS-C
Rationale: It is likely that the first catheter is in the vagina, rather than the bladder.
Leaving the first catheter in place will help locate the meatus when attempting the
second catheterization. The client should have at least 240 mL of urine after 8 hours.
Option A does not resolve the problem. Option B will not change the location of the
catheter unless it is completely removed, in which case a new catheter must be used.
There is no evidence of a urinary tract obstruction if the catheter could be easily
inserted.
Which serum laboratory value should the nurse monitor carefully for a client who has a
nasogastric (NG) tube to suction for the past week?
A.
White blood cell count
B.
Albumin
C.
Calcium
D.
Sodium
- CORRECT ANS-D
Rationale: Monitoring serum sodium levels for hyponatremia is indicated during
prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or
C are not typically associated with prolonged NG suctioning.
