HESI RN Fundamentals V1 – Actual Exam Questions & Verified Answers with Rationales –
100% Toetsgericht – LAATST BIJGEWERKT 2025
A post-operative client has three different PRN analgesics prescribed for different levels of pain. The nurse
inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take
first?
A: Determine if the pain was relieved.
B: Complete a medication error report.
C: Assess for side effects of the medication.
D: Document the client's responses.
Assess for side effects of the medication.
The UAP describes the appearance of the bowel movements of several clients. Which descriptions warrant
additional follow-up by the nurse?(SATA)
A: Multiple hard pellets
B: Brown liquid
C: Formed but soft
D: Solid with red streaks
E: Tarry appearance
Multiple hard pellets
Brown liquid
Solid with red streaks
Tarry appearance
An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear,
which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most
important for the nurse to include in the client's teaching plan?
A: The importance of using vaginal lubricants.
B: Methods used to practice safe sex.
C: Information about alternative ways to express sexuality.
D: Intercourse positions that help prevent tears.
The importance of using vaginal lubricants.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%,
which is the same reading obtained prior to starting the procedure. What action would the nurse take in response
to this finding?
A: Reposition the pulse oximeter clip to obtain a new reading.
,B: Stop suctioning until the pulse oximeter reading is above 95%.
C: Complete the intermittent suction of the nasopharynx.
D: Apply an oxygen mask over the client's nose and mouth.
Complete the intermittent suction of the nasopharynx.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and
requests that no heroic measures are implemented if her breathing stops. What actions should the nurse take
first?
A: Discuss with the client her meaning of heroic measures.
B: Obtain a DNR.
C: Set up a family conference to discuss the client.
D: Consult the palliative care team about the client's care.
Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine
HCl. What instruction should the nurse plan to include in this client's teaching?
A: "Do not allow the dropper bottle to touch the eye."
B: "Administer the medication directly on the cornea."
C: Squeeze the eye closed after administering the drops."
D: Wash your hands after administration of eye drops."
"Do not allow the dropper bottle to touch the eye."
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client
assessment findings indicate the need to assign the UAP to provide routine foot care and file the client's
toenails?(SATA)
A: Syncope when bending.
B: Hand tremors.
C: Diminished visual acuity.
D: Urinary incontinence.
E: Shuffling gait.
Syncope when bending.
Hand tremors.
Diminished visual acuity.
The client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action
should be included in the plan to reduce the client's risk for infection related to the catheter?
A: Flush the catheter daily with sterile saline.
B: Encourage increase intake of oral fluids.
, C: Administer a PRN antipyretic if a fever develops.
D: Secure the drainage bag at bladder level during transport.
Encourage increase intake of oral fluids.
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do
not have long to live." Which response is best for the nurse to provide?
A: "That's correct. You do not have long to live."
B: "Would you like me to call your minister?"
C: "Don't give up, you still have chemotherapy to try."
D: "Yes, your condition is serious."
"Yes, your condition is serious."
When performing blood pressure measurement to assess for orthostatic hypotension, which action should the
nurse implement first?
A: Apply the blood pressure cuff securely.
B: Record the client's pulse rate and rhythm.
C: Position the client supine for a few minutes.
D: Assist client to stand at bedside.
Position the client supine for a few minutes.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes
identified in the plan of care. What action should the nurse take next?
A: Modify the nursing interventions to achieve the client's goals.
B: Determine if the expected outcomes were realistic.
C: Review related professional standards of care.
D: Obtain current client data to compare with expected outcomes.
Obtain current client data to compare with expected outcomes.
A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions
should the nurse give to the UAP who is assisting with the client's care?(SATA)
A: Instruct the client about signs of orthostatic hypertension.
B: Determine if the client needs to have a gait belt applied.
C: Measure the client's vital signs before the client walks.
D: Offer to assist the client to void prior to walking in the hall.
E: Report the onset of any dizziness or lightheadedness.
Measure the client's vital signs before the client walks.
Offer to assist the client to void prior to walking in the hall.
Report the onset of any dizziness or lightheadedness.
100% Toetsgericht – LAATST BIJGEWERKT 2025
A post-operative client has three different PRN analgesics prescribed for different levels of pain. The nurse
inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take
first?
A: Determine if the pain was relieved.
B: Complete a medication error report.
C: Assess for side effects of the medication.
D: Document the client's responses.
Assess for side effects of the medication.
The UAP describes the appearance of the bowel movements of several clients. Which descriptions warrant
additional follow-up by the nurse?(SATA)
A: Multiple hard pellets
B: Brown liquid
C: Formed but soft
D: Solid with red streaks
E: Tarry appearance
Multiple hard pellets
Brown liquid
Solid with red streaks
Tarry appearance
An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear,
which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most
important for the nurse to include in the client's teaching plan?
A: The importance of using vaginal lubricants.
B: Methods used to practice safe sex.
C: Information about alternative ways to express sexuality.
D: Intercourse positions that help prevent tears.
The importance of using vaginal lubricants.
While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%,
which is the same reading obtained prior to starting the procedure. What action would the nurse take in response
to this finding?
A: Reposition the pulse oximeter clip to obtain a new reading.
,B: Stop suctioning until the pulse oximeter reading is above 95%.
C: Complete the intermittent suction of the nasopharynx.
D: Apply an oxygen mask over the client's nose and mouth.
Complete the intermittent suction of the nasopharynx.
An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and
requests that no heroic measures are implemented if her breathing stops. What actions should the nurse take
first?
A: Discuss with the client her meaning of heroic measures.
B: Obtain a DNR.
C: Set up a family conference to discuss the client.
D: Consult the palliative care team about the client's care.
Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine
HCl. What instruction should the nurse plan to include in this client's teaching?
A: "Do not allow the dropper bottle to touch the eye."
B: "Administer the medication directly on the cornea."
C: Squeeze the eye closed after administering the drops."
D: Wash your hands after administration of eye drops."
"Do not allow the dropper bottle to touch the eye."
The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client
assessment findings indicate the need to assign the UAP to provide routine foot care and file the client's
toenails?(SATA)
A: Syncope when bending.
B: Hand tremors.
C: Diminished visual acuity.
D: Urinary incontinence.
E: Shuffling gait.
Syncope when bending.
Hand tremors.
Diminished visual acuity.
The client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action
should be included in the plan to reduce the client's risk for infection related to the catheter?
A: Flush the catheter daily with sterile saline.
B: Encourage increase intake of oral fluids.
, C: Administer a PRN antipyretic if a fever develops.
D: Secure the drainage bag at bladder level during transport.
Encourage increase intake of oral fluids.
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I have cancer and do
not have long to live." Which response is best for the nurse to provide?
A: "That's correct. You do not have long to live."
B: "Would you like me to call your minister?"
C: "Don't give up, you still have chemotherapy to try."
D: "Yes, your condition is serious."
"Yes, your condition is serious."
When performing blood pressure measurement to assess for orthostatic hypotension, which action should the
nurse implement first?
A: Apply the blood pressure cuff securely.
B: Record the client's pulse rate and rhythm.
C: Position the client supine for a few minutes.
D: Assist client to stand at bedside.
Position the client supine for a few minutes.
When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes
identified in the plan of care. What action should the nurse take next?
A: Modify the nursing interventions to achieve the client's goals.
B: Determine if the expected outcomes were realistic.
C: Review related professional standards of care.
D: Obtain current client data to compare with expected outcomes.
Obtain current client data to compare with expected outcomes.
A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions
should the nurse give to the UAP who is assisting with the client's care?(SATA)
A: Instruct the client about signs of orthostatic hypertension.
B: Determine if the client needs to have a gait belt applied.
C: Measure the client's vital signs before the client walks.
D: Offer to assist the client to void prior to walking in the hall.
E: Report the onset of any dizziness or lightheadedness.
Measure the client's vital signs before the client walks.
Offer to assist the client to void prior to walking in the hall.
Report the onset of any dizziness or lightheadedness.
