1
NURSING HESI FUNDAMENTALS EXAM NEWEST
2024-2025 ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS
The nurse removes the dressing on a client's heel that is covering a pressure
sore one-inch in diameter and finds that there is straw-colored drainage
seeping from the wound. What description of this finding should the nurse
include in the client's record?
A) Stage 1 pressure sore draining sero-sanguineous drainage.
B) Pressure sore at bony prominence with exudate noted.
C) One-inch pressure sore draining serous fluid.
D) Pressure sore on heel with a small amount of purulent drainage. -
(answers)Answer: C
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate
documentation based on the information provided. Information to stage this
pressure score (A) is not provided, and sero-sanguineous drainage is pale and
watery with a combination of plasma and red cells, and may be blood-streaked.
Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick,
yellow, green, or brown indicating the presence of dead or living organisms and
white blood cells.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old
boy in the treatment room, he cries continuously. What intervention should
the nurse implement?
A) Take the child back to his room.
B) Recruit others to restrain the child.
C) Ask the mother to be present to soothe the child.
, 2
D) Show the child how to manipulate the equipment. - (answers)Answer: C
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking
abilities. The mother's assistance (C) can provide a stabilizing presence to help
soothe the preschooler, who may perceive the invasive procedure as
mutilating. To preserve the child's sense of security associated with the hospital
room, it is best to perform difficult or painful procedures in another area (A).
(B) may be necessary to prevent injury if the child is unable to cooperate with
the mother's coaxing. (D) is best done before going to the treatment room
when the child feels less threatened.
On the third postoperative day following thoracic surgery, a client reports
feeling constipated. Which intervention should the nurse implement to
promote bowel elimination?
A) Remind the client to turn every two hours while lying in bed.
B) Provide warm prune juice before the client goes to bed at night.
C) Teach the client to splint the incision while walking to the bathroom.
D) Administer an analgesic before the client attempts to defecate. -
(answers)Answer: B
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the
prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis
but is less likely to relieve the client's constipation. (C) reduces discomfort
during ambulation, but will not help relieve the client's constipation.
Defecation is not painful following most surgeries, and many analgesics used
postoperatively cause constipation, so (D) is contraindicated.
To obtain the most complete assessment data for a client with chronic pain,
which information should the nurse obtain?
, 3
A) Can you describe where your pain is the most severe?
B) What is your pain intensity on a scale of 1 to 10?
C) Is your pain best described as aching, throbbing, or sharp?
D) Which activities during a routine day are impacted by your pain? -
(answers)Answer: D
Rationale
A client with chronic pain is more likely to have adapted physiologically to vital
sign changes, localization or intensity, so pain assessment should focus on any
interference with daily activities (D), such as sleep, relationships with others,
physical activity, and emotional well-being. Exacerbation of acute symptoms,
such as pain distribution, patterns, intensity, and descriptors elicit specific
assessment findings, whereas (A, B, and C) are limiting, closed-end questions,
and can be answered with a yes, no, or a number.
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The
nurse determines that the client has been noncompliant with the diet, based
on which report from the 24-hour dietary recall? (Select all that apply.)
A) Snack of potato chips, and diet soda.
B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C) Breakfast of eggs, bacon, toast, and coffee.
D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E) Bedtime snack of crackers and milk. - (answers)Answers: A, C
Rationale
, 4
Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and
crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a
low sodium, low protein diet.
A client provides the nurse with information about the reason for seeking care.
The nurse realizes that some information about past hospitalizations is missing.
How should the nurse obtain this information?
A) Solicit information on hospitalization from the insurance company.
B) Look up previous medical records from archived hospital documents.
C) Ask the client to discuss previous hospitalizations in the last 5 years.
D) Elicit specific facts about past hospitalizations with direct questions. -
(answers)Answer: D
Rationale
Direct questions should be used after the client's opening narrative to fill in any
details that have been left out or during the review of systems to elicit specific
facts about past health problems.
An older female client with rheumatoid arthritis is complaining of severe joint
pain that is caused by the weight of the linen on her legs. What action should
the nurse implement first?
A) Apply flannel pajamas to provide warmth.
B) Administer a PRN dose of ibuprofen.
C) Perform range of motion exercises in a warm tub.
D) Drape the sheets over the footboard of the bed. - (answers)Answer: D
Rationale
NURSING HESI FUNDAMENTALS EXAM NEWEST
2024-2025 ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS
The nurse removes the dressing on a client's heel that is covering a pressure
sore one-inch in diameter and finds that there is straw-colored drainage
seeping from the wound. What description of this finding should the nurse
include in the client's record?
A) Stage 1 pressure sore draining sero-sanguineous drainage.
B) Pressure sore at bony prominence with exudate noted.
C) One-inch pressure sore draining serous fluid.
D) Pressure sore on heel with a small amount of purulent drainage. -
(answers)Answer: C
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate
documentation based on the information provided. Information to stage this
pressure score (A) is not provided, and sero-sanguineous drainage is pale and
watery with a combination of plasma and red cells, and may be blood-streaked.
Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick,
yellow, green, or brown indicating the presence of dead or living organisms and
white blood cells.
As the nurse prepares the equipment to be used to start an IV on a 4-year-old
boy in the treatment room, he cries continuously. What intervention should
the nurse implement?
A) Take the child back to his room.
B) Recruit others to restrain the child.
C) Ask the mother to be present to soothe the child.
, 2
D) Show the child how to manipulate the equipment. - (answers)Answer: C
Rationale
A 4-year-old typically has a vivid imagination and lacks concrete thinking
abilities. The mother's assistance (C) can provide a stabilizing presence to help
soothe the preschooler, who may perceive the invasive procedure as
mutilating. To preserve the child's sense of security associated with the hospital
room, it is best to perform difficult or painful procedures in another area (A).
(B) may be necessary to prevent injury if the child is unable to cooperate with
the mother's coaxing. (D) is best done before going to the treatment room
when the child feels less threatened.
On the third postoperative day following thoracic surgery, a client reports
feeling constipated. Which intervention should the nurse implement to
promote bowel elimination?
A) Remind the client to turn every two hours while lying in bed.
B) Provide warm prune juice before the client goes to bed at night.
C) Teach the client to splint the incision while walking to the bathroom.
D) Administer an analgesic before the client attempts to defecate. -
(answers)Answer: B
Rationale
Prune juice is a natural laxative that stimulates peristalsis, and warming the
prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis
but is less likely to relieve the client's constipation. (C) reduces discomfort
during ambulation, but will not help relieve the client's constipation.
Defecation is not painful following most surgeries, and many analgesics used
postoperatively cause constipation, so (D) is contraindicated.
To obtain the most complete assessment data for a client with chronic pain,
which information should the nurse obtain?
, 3
A) Can you describe where your pain is the most severe?
B) What is your pain intensity on a scale of 1 to 10?
C) Is your pain best described as aching, throbbing, or sharp?
D) Which activities during a routine day are impacted by your pain? -
(answers)Answer: D
Rationale
A client with chronic pain is more likely to have adapted physiologically to vital
sign changes, localization or intensity, so pain assessment should focus on any
interference with daily activities (D), such as sleep, relationships with others,
physical activity, and emotional well-being. Exacerbation of acute symptoms,
such as pain distribution, patterns, intensity, and descriptors elicit specific
assessment findings, whereas (A, B, and C) are limiting, closed-end questions,
and can be answered with a yes, no, or a number.
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The
nurse determines that the client has been noncompliant with the diet, based
on which report from the 24-hour dietary recall? (Select all that apply.)
A) Snack of potato chips, and diet soda.
B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C) Breakfast of eggs, bacon, toast, and coffee.
D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E) Bedtime snack of crackers and milk. - (answers)Answers: A, C
Rationale
, 4
Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and
crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a
low sodium, low protein diet.
A client provides the nurse with information about the reason for seeking care.
The nurse realizes that some information about past hospitalizations is missing.
How should the nurse obtain this information?
A) Solicit information on hospitalization from the insurance company.
B) Look up previous medical records from archived hospital documents.
C) Ask the client to discuss previous hospitalizations in the last 5 years.
D) Elicit specific facts about past hospitalizations with direct questions. -
(answers)Answer: D
Rationale
Direct questions should be used after the client's opening narrative to fill in any
details that have been left out or during the review of systems to elicit specific
facts about past health problems.
An older female client with rheumatoid arthritis is complaining of severe joint
pain that is caused by the weight of the linen on her legs. What action should
the nurse implement first?
A) Apply flannel pajamas to provide warmth.
B) Administer a PRN dose of ibuprofen.
C) Perform range of motion exercises in a warm tub.
D) Drape the sheets over the footboard of the bed. - (answers)Answer: D
Rationale
