HESI:l NURl 104/l NUR104l (NEWl 2025/l
2026l Update)l Foundationsl ofl Nursingl
Examl Review|l Questionsl &l Answers|l
Gradel A|l 100%l Correctl (Verifiedl
Solutions)-l Fortis
QUESTION
Al clientl onl al prescribedl fulll liquidl dietl hasl al nursingl diagnosisl ofl "Riskl forl impairedl
skinl integrityl relatedl tol reducedl orall intake."l Whatl snackl isl bestl tol providel thisl client?
A:l Beefl brothl orl chickenl broth.
B:l Purifiedl lowfatl milk.
C:l Applel orl grapefruitl juice.
D:l Ensure,l al liquidl supplement.
Answer:
D:l Ensure,l al liquidl supplement.
QUESTION
Thel healthcarel providerl prescribesl bladderl irrigationl tol maintainl patencyl ofl al client'sl
indwellingl urinaryl catheter.l Whichl interventionl shouldl thel nursel implement?
A:l Usel al sterilel syringel tol irrigatel withl NSl 20l ml.
B:l Usel anl infusionl pumpl tol slowlyl irrigatel thel indwellingl catheter.
C:l Clampl thel catheterl forl 30l minutesl priorl tol irrigatingl withl NS.
D:l Powerl flushl withl NSl 60l mll tol removel mucous.
Answer:
A:l Usel al sterilel syringel tol irrigatel withl NSl 20l ml.
,QUESTION
Twol nursesl assessl al clientl forl al pulsel deficitl andl countl anl apicall pulsel ofl 72l
beats/minutel andl al radiall pulsel ofl 88l beats/minute.l Whatl actionl shouldl thel nursel takel
first?
A:l Obtainl al secondl pulsel deficitl reading.
B:l Reportl thel resultsl tol thel healthcarel provider.
C:l Measurel thel client'sl bloodl pressure.
D:l Documentl al pulsel deficitl ofl 16l bpm.
Answer:
B:l Reportl thel resultsl tol thel healthcarel provider.
QUESTION
Thel femalel clientl whol isl onel dayl postl mastectomyl isl cryingl whenl thel nursel entersl thel
room.l Whatl actionl shouldl thel nursel take?
A:l Remainl quietlyl byl thel doorl untill thel clientl stopsl crying.
B:l Stayl withl thel clientl inl silencel whilel touchingl herl forearm.
C:l Askl thel clientl ifl shel wouldl likel herl clergyl notified.
D:l Telll thel clientl itl isl normall tol cryl afterl surgery.
Answer:
B:l Stayl withl thel clientl inl silencel whilel touchingl herl forearm.
QUESTION
Al 24-hourl urinel collectionl isl inl progress.l Thel clientl tellsl thel nursel thatl thel lastl
voidingl wasl accidentallyl flushedl insteadl ofl savedl inl thel container.l Whatl interventionsl
shouldl thel nursel initiate?
A:l Discardl thel urinel andl startl anotherl 24l hourl period.
B:l Notifyl thel chargel nursel ofl thel problem.
C:l Notifyl thel healthcarel providerl ofl thel situation.
D:l Addl anotherl hourl tol thel urinel collectionl period.
Answer:
A:l Discardl thel urinel andl startl anotherl 24l hourl period.
,QUESTION
Al youngl malel clientl withl testicularl cancerl hasl al livingl willl thatl describesl hisl desirel
thatl nol extraordinaryl measuresl bel takenl tol savel hisl life.l Thel healthcarel providerl knowsl
thel clientl hasl goodl prognosisl andl refusesl tol writel al DNRl prescription.l Whatl actionl
shouldl thel nursel take?
A:l Initiatel anl ethicsl committeel reviewl ofl thel case.
B:l Ensurel resuscitationl isl available.
C:l Placel al DNRl braceletl onl thel client'sl arm.
D:l Askl thel familyl tol reviewl optionsl withl thel client.
Answer:
A:l Initiatel anl ethicsl committeel reviewl ofl thel case.
QUESTION
Al confusedl elderlyl malel clientl isl havingl troublel sleepingl atl nightl andl isl sometimesl
foundl wonderingl inl thel hallway.l Whatl nursingl interventionl shouldl thel nursel implementl
first?
A:l Applyl wristl restraintsl tol preventl wandering.
B:l Providel al backl rubl atl bedtime.
C:l Leavel thel doorl tol hisl rooml openl slightly.
D:l Administerl al PRNl sedativel prescription.
Answer:
B:l Providel al backl rubl atl bedtime.
QUESTION
Thel nursel isl preparingl tol feedl al newlyl administeredl elderlyl malel clientl whol isl
debilitatedl butl isl ablel tol respondl tol mostl commands.l Beforel startingl tol feedl thel client,l
whichl informationl isl mostl importantl forl thel nursel tol obtain?
A:l Client'sl respiratoryl ratel andl lungl sounds.
B:l Prescribedl diet.
C:l Client'sl abilityl tol chewl andl swallow.
D:l Currentl medications.
, Answer:
C:l Client'sl abilityl tol chewl andl swallow.
QUESTION
Thel nursel entersl thel rooml ofl al clientl withl Clostridiuml difficilel infectionl tol administerl
anl IVl antibiotic.l Thel UAPl isl inl thel rooml cleaningl thel client'sl buttocksl andl statesl thel
clientl hasl beenl incontinentl withl diarrhea.l Thel UAPl isl wearingl glovesl butl notl al gown.l
Whatl actionl shouldl thel nursel implementl first?
A:l Advisel thel UAPl tol putl onl al gown.
B:l Observel thel appearancel ofl thel diarrhea.
C:l Hangl thel scheduledl dosel ofl antibiotic.
D:l Assessl thel client'sl skinl integrity.
Answer:
A:l Advisel thel UAPl tol putl onl al gown.
QUESTION
Afterl reviewingl thel admissionl assessmentl ofl al clientl withl chronicl pain,l whichl
interventionsl shouldl thel nursel includel inl thisl client'sl planl ofl care?(SATA)
A:l Providel comfortl measuresl suchl asl topicall warml applicationl andl tactilel massage.
B:l Encouragel increasedl fluidl intakel andl measurel urinaryl outputl Q8l hours.
C:l Implementl al 24-hourl schedulel ofl routinel administrationl ofl prescribedl analgesic.
D:l Determinel client'sl subjectivel measurel ofl painl usingl al numericall painl scale.
E:l Assistl thel clientl tol ambulatel asl muchl asl possiblel duringl wakingl hours.
Answer:
A,l C,l D,l E
QUESTION
Thel grandmotherl ofl al youngl adultl malel admittedl tol thel psychiatricl unitl yesterdayl
requestsl informationl aboutl herl grandson'sl treatmentl plan.l Beforel answeringl thel familyl
member'sl questions,l whatl actionl shouldl thel nursel take?
A:l Askl thel clientl ifl hel wantsl thisl informationl sharedl withl hisl grandmother.
2026l Update)l Foundationsl ofl Nursingl
Examl Review|l Questionsl &l Answers|l
Gradel A|l 100%l Correctl (Verifiedl
Solutions)-l Fortis
QUESTION
Al clientl onl al prescribedl fulll liquidl dietl hasl al nursingl diagnosisl ofl "Riskl forl impairedl
skinl integrityl relatedl tol reducedl orall intake."l Whatl snackl isl bestl tol providel thisl client?
A:l Beefl brothl orl chickenl broth.
B:l Purifiedl lowfatl milk.
C:l Applel orl grapefruitl juice.
D:l Ensure,l al liquidl supplement.
Answer:
D:l Ensure,l al liquidl supplement.
QUESTION
Thel healthcarel providerl prescribesl bladderl irrigationl tol maintainl patencyl ofl al client'sl
indwellingl urinaryl catheter.l Whichl interventionl shouldl thel nursel implement?
A:l Usel al sterilel syringel tol irrigatel withl NSl 20l ml.
B:l Usel anl infusionl pumpl tol slowlyl irrigatel thel indwellingl catheter.
C:l Clampl thel catheterl forl 30l minutesl priorl tol irrigatingl withl NS.
D:l Powerl flushl withl NSl 60l mll tol removel mucous.
Answer:
A:l Usel al sterilel syringel tol irrigatel withl NSl 20l ml.
,QUESTION
Twol nursesl assessl al clientl forl al pulsel deficitl andl countl anl apicall pulsel ofl 72l
beats/minutel andl al radiall pulsel ofl 88l beats/minute.l Whatl actionl shouldl thel nursel takel
first?
A:l Obtainl al secondl pulsel deficitl reading.
B:l Reportl thel resultsl tol thel healthcarel provider.
C:l Measurel thel client'sl bloodl pressure.
D:l Documentl al pulsel deficitl ofl 16l bpm.
Answer:
B:l Reportl thel resultsl tol thel healthcarel provider.
QUESTION
Thel femalel clientl whol isl onel dayl postl mastectomyl isl cryingl whenl thel nursel entersl thel
room.l Whatl actionl shouldl thel nursel take?
A:l Remainl quietlyl byl thel doorl untill thel clientl stopsl crying.
B:l Stayl withl thel clientl inl silencel whilel touchingl herl forearm.
C:l Askl thel clientl ifl shel wouldl likel herl clergyl notified.
D:l Telll thel clientl itl isl normall tol cryl afterl surgery.
Answer:
B:l Stayl withl thel clientl inl silencel whilel touchingl herl forearm.
QUESTION
Al 24-hourl urinel collectionl isl inl progress.l Thel clientl tellsl thel nursel thatl thel lastl
voidingl wasl accidentallyl flushedl insteadl ofl savedl inl thel container.l Whatl interventionsl
shouldl thel nursel initiate?
A:l Discardl thel urinel andl startl anotherl 24l hourl period.
B:l Notifyl thel chargel nursel ofl thel problem.
C:l Notifyl thel healthcarel providerl ofl thel situation.
D:l Addl anotherl hourl tol thel urinel collectionl period.
Answer:
A:l Discardl thel urinel andl startl anotherl 24l hourl period.
,QUESTION
Al youngl malel clientl withl testicularl cancerl hasl al livingl willl thatl describesl hisl desirel
thatl nol extraordinaryl measuresl bel takenl tol savel hisl life.l Thel healthcarel providerl knowsl
thel clientl hasl goodl prognosisl andl refusesl tol writel al DNRl prescription.l Whatl actionl
shouldl thel nursel take?
A:l Initiatel anl ethicsl committeel reviewl ofl thel case.
B:l Ensurel resuscitationl isl available.
C:l Placel al DNRl braceletl onl thel client'sl arm.
D:l Askl thel familyl tol reviewl optionsl withl thel client.
Answer:
A:l Initiatel anl ethicsl committeel reviewl ofl thel case.
QUESTION
Al confusedl elderlyl malel clientl isl havingl troublel sleepingl atl nightl andl isl sometimesl
foundl wonderingl inl thel hallway.l Whatl nursingl interventionl shouldl thel nursel implementl
first?
A:l Applyl wristl restraintsl tol preventl wandering.
B:l Providel al backl rubl atl bedtime.
C:l Leavel thel doorl tol hisl rooml openl slightly.
D:l Administerl al PRNl sedativel prescription.
Answer:
B:l Providel al backl rubl atl bedtime.
QUESTION
Thel nursel isl preparingl tol feedl al newlyl administeredl elderlyl malel clientl whol isl
debilitatedl butl isl ablel tol respondl tol mostl commands.l Beforel startingl tol feedl thel client,l
whichl informationl isl mostl importantl forl thel nursel tol obtain?
A:l Client'sl respiratoryl ratel andl lungl sounds.
B:l Prescribedl diet.
C:l Client'sl abilityl tol chewl andl swallow.
D:l Currentl medications.
, Answer:
C:l Client'sl abilityl tol chewl andl swallow.
QUESTION
Thel nursel entersl thel rooml ofl al clientl withl Clostridiuml difficilel infectionl tol administerl
anl IVl antibiotic.l Thel UAPl isl inl thel rooml cleaningl thel client'sl buttocksl andl statesl thel
clientl hasl beenl incontinentl withl diarrhea.l Thel UAPl isl wearingl glovesl butl notl al gown.l
Whatl actionl shouldl thel nursel implementl first?
A:l Advisel thel UAPl tol putl onl al gown.
B:l Observel thel appearancel ofl thel diarrhea.
C:l Hangl thel scheduledl dosel ofl antibiotic.
D:l Assessl thel client'sl skinl integrity.
Answer:
A:l Advisel thel UAPl tol putl onl al gown.
QUESTION
Afterl reviewingl thel admissionl assessmentl ofl al clientl withl chronicl pain,l whichl
interventionsl shouldl thel nursel includel inl thisl client'sl planl ofl care?(SATA)
A:l Providel comfortl measuresl suchl asl topicall warml applicationl andl tactilel massage.
B:l Encouragel increasedl fluidl intakel andl measurel urinaryl outputl Q8l hours.
C:l Implementl al 24-hourl schedulel ofl routinel administrationl ofl prescribedl analgesic.
D:l Determinel client'sl subjectivel measurel ofl painl usingl al numericall painl scale.
E:l Assistl thel clientl tol ambulatel asl muchl asl possiblel duringl wakingl hours.
Answer:
A,l C,l D,l E
QUESTION
Thel grandmotherl ofl al youngl adultl malel admittedl tol thel psychiatricl unitl yesterdayl
requestsl informationl aboutl herl grandson'sl treatmentl plan.l Beforel answeringl thel familyl
member'sl questions,l whatl actionl shouldl thel nursel take?
A:l Askl thel clientl ifl hel wantsl thisl informationl sharedl withl hisl grandmother.
