HESI NURSING FUNDAMENTALS EXAM
2025 QUESTIONS AND 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. - ANS 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.
D) Show the child how to manipulate the equipment. - ANS Answer: C
Rationale
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,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. - ANS 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?
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? - ANS 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
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 2
,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. - ANS Answers: A, C
Rationale
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. - ANS 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?
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 3
, 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. - ANS Answer: D
Rationale
The nurse should first provide an immediate comfort measure to address the client's complaint
about the linens and drape the linens over the footboard of the bed (D) instead of tucking them
under the mattress, which can add pressure perceived by the client as the source of her pain.
(A, B, and C) may be components of the client's plan of care, but the nurse should first address
the client's complaint.
A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a
scheduled chemotherapy treatment, and states that she is ready to go home to die. What
intervention should the nurse initiate?
A) Review the client's medical record for an advance directive.
B) Determine if a do-not-resuscitate prescription has been obtained.
C) Document that the client is being discharged against medical advice.
D) Evaluate the client's mental status for competence to refuse treatment. - ANS Answer: D
Rationale
Competent clients have the right to refuse treatment, so the nurse should first ensure that the
client is competent (D). (A and C) are not necessary for a competent client to refuse treatment.
The nurse cannot document (C) until the healthcare provider is notified of the client's wishes
and a discharge prescription is obtained.
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to
impending death." What intervention is best for the nurse to implement when caring for this
client?
A) Help the client to accept the final stage of life.
B) Assist and support the client in establishing short-term goals.
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 4
2025 QUESTIONS AND 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. - ANS 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.
D) Show the child how to manipulate the equipment. - ANS Answer: C
Rationale
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 1
,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. - ANS 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?
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? - ANS 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
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 2
,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. - ANS Answers: A, C
Rationale
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. - ANS 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?
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 3
, 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. - ANS Answer: D
Rationale
The nurse should first provide an immediate comfort measure to address the client's complaint
about the linens and drape the linens over the footboard of the bed (D) instead of tucking them
under the mattress, which can add pressure perceived by the client as the source of her pain.
(A, B, and C) may be components of the client's plan of care, but the nurse should first address
the client's complaint.
A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a
scheduled chemotherapy treatment, and states that she is ready to go home to die. What
intervention should the nurse initiate?
A) Review the client's medical record for an advance directive.
B) Determine if a do-not-resuscitate prescription has been obtained.
C) Document that the client is being discharged against medical advice.
D) Evaluate the client's mental status for competence to refuse treatment. - ANS Answer: D
Rationale
Competent clients have the right to refuse treatment, so the nurse should first ensure that the
client is competent (D). (A and C) are not necessary for a competent client to refuse treatment.
The nurse cannot document (C) until the healthcare provider is notified of the client's wishes
and a discharge prescription is obtained.
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to
impending death." What intervention is best for the nurse to implement when caring for this
client?
A) Help the client to accept the final stage of life.
B) Assist and support the client in establishing short-term goals.
COPYRIGHT © 2025 FYNDLAY ALL RIGHTS RESERVED 4
