Nursing HESI Fundamentals Actual Exam 2025/2026
– Verified Questions and Correct Detailed Answers |
Graded A+ and Fully Updated
Question 1: A nurse is assessing a client with suspected dehydration. Which clinical
manifestation should the nurse prioritize as an indicator of fluid volume
deficit?
A. Increased urine output
B. Bounding pulse
C. Dry mucous membranes
D. Elevated blood pressure
Correct Answer: C. Dry mucous membranes
Rationale: Dry mucous membranes are a hallmark sign of dehydration
due to decreased fluid volume in the body, leading to reduced moisture in
mucosal tissues. Increased urine output (A) is not associated with dehy-
dration, as urine output typically decreases. A bounding pulse (B) is more
indicative of fluid overload or cardiovascular issues. Elevated blood pres-
sure (D) is not a primary sign of dehydration; hypotension is more common
due to reduced circulating volume.
Question 2: A client with a nasogastric tube reports nausea. What is the nurse’s first
action?
A. Administer an antiemetic medication
B. Check the tube for proper placement
C. Increase the suction pressure
D. Flush the tube with normal saline
Correct Answer: B. Check the tube for proper placement
Rationale: Nausea in a client with a nasogastric tube may indicate im-
proper placement, obstruction, or irritation. Verifying tube placement en-
sures it is in the stomach and not causing complications. Administering an
antiemetic (A) addresses the symptom but not the cause. Increasing suc-
tion pressure (C) could worsen irritation or cause tissue damage. Flushing
the tube (D) is appropriate after confirming placement.
Question 3: A nurse is preparing to administer a medication via intramuscular injec-
tion. Which site is most appropriate for an adult client?
A. Vastus lateralis
B. Deltoid
C. Ventrogluteal
D. Dorsogluteal
Correct Answer: C. Ventrogluteal
Rationale: The ventrogluteal site is preferred for intramuscular injections
in adults due to its large muscle mass, minimal nerve presence, and re-
duced risk of complications. The vastus lateralis (A) is suitable but less pre-
ferred for adults. The deltoid (B) has limited muscle mass for larger vol-
umes. The dorsogluteal site (D) is avoided due to the risk of sciatic nerve
injury.
1
,Question 4: When teaching a client about a low-sodium diet, which food should the
nurse recommend limiting?
A. Fresh apples
B. Canned soup
C. Grilled chicken
D. Brown rice
Correct Answer: B. Canned soup
Rationale: Canned soup is high in sodium due to preservatives, making it
a poor choice for a low-sodium diet. Fresh apples (A), grilled chicken (C),
and brown rice (D) are naturally low in sodium and suitable for the diet.
Question 5: A client with a history of heart failure is prescribed furosemide. Which
electrolyte imbalance should the nurse monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B. Hypokalemia
Rationale: Furosemide, a loop diuretic, promotes potassium excretion, in-
creasing the risk of hypokalemia. Hyperkalemia (A) is less likely with di-
uretics. Hypernatremia (C) is not typically associated with furosemide, which
causes sodium loss. Hypocalcemia (D) is not a primary concern with this
medication.
Question 6: A nurse is caring for a client with a pressure injury. Which intervention
promotes wound healing?
A. Keeping the wound dry and uncovered
B. Applying a moist dressing
C. Massaging the surrounding tissue
D. Using a heat lamp on the wound
Correct Answer: B. Applying a moist dressing
Rationale: A moist environment supports wound healing by promoting
cell migration and preventing tissue dehydration. Keeping the wound dry
(A) delays healing. Massaging surrounding tissue (C) can cause further tis-
sue damage. Heat lamps (D) are not recommended due to the risk of burns.
Question 7: A client is receiving oxygen at 2 L/min via nasal cannula. What should the
nurse monitor to ensure safe oxygen administration?
A. Skin integrity around the cannula
B. Blood pressure every 4 hours
C. Urine output every shift
D. Room temperature
Correct Answer: A. Skin integrity around the cannula
Rationale: Prolonged use of a nasal cannula can cause skin breakdown
due to pressure and moisture. Blood pressure (B) and urine output (C) are
not directly related to oxygen administration. Room temperature (D) is less
critical than skin assessment.
Question 8: A nurse is teaching a client about proper body mechanics. Which statement
by the client indicates understanding?
2
, A. “I should bend at the waist to lift heavy objects.”
B. “I should keep objects close to my body when lifting.”
C. “I should twist my torso while carrying heavy loads.”
D. “I should lift with my arms fully extended.”
Correct Answer: B. I should keep objects close to my body when lifting.
Rationale: Keeping objects close to the body reduces strain on the back and
maintains balance. Bending at the waist (A) or twisting (C) increases injury
risk. Lifting with extended arms (D) strains muscles and joints.
Question 9: A client with diabetes mellitus reports feeling shaky and sweaty. What is
the nurse’s priority action?
A. Administer insulin
B. Check blood glucose level
C. Provide a high-protein snack
D. Encourage fluid intake
Correct Answer: B. Check blood glucose level
Rationale: Shaking and sweating suggest hypoglycemia. Checking blood
glucose confirms the diagnosis and guides treatment. Administering in-
sulin (A) could worsen hypoglycemia. A high-protein snack (C) is less effec-
tive than a fast-acting carbohydrate. Fluid intake (D) does not address the
immediate issue.
Question 10: A nurse is preparing to insert a urinary catheter. Which action ensures a
sterile technique?
A. Using clean gloves during insertion
B. Opening the sterile kit away from the body
C. Cleansing the meatus after catheter insertion
D. Holding the catheter with bare hands
Correct Answer: B. Opening the sterile kit away from the body
Rationale: Opening the sterile kit away from the body prevents contami-
nation of the sterile field. Clean gloves (A) are insufficient; sterile gloves are
required. Cleansing the meatus after insertion (C) is incorrect; it should be
done before. Holding the catheter with bare hands (D) breaks sterile tech-
nique.
Question 11: A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen therapy. Which position should the nurse recommend to improve
breathing?
A. Supine with head elevated
B. Prone with arms extended
C. Fowler’s position
D. Side-lying with knees bent
Correct Answer: C. Fowler’s position
Rationale: Fowler’s position (semi-upright) promotes lung expansion and
eases breathing in clients with COPD. Supine (A) may restrict lung expan-
sion. Prone (B) is uncomfortable and not ideal for breathing. Side-lying (D)
is less effective for respiratory distress.
Question 12: A nurse is assessing a client’s peripheral pulses. Which finding indicates a
normal pulse?
3
– Verified Questions and Correct Detailed Answers |
Graded A+ and Fully Updated
Question 1: A nurse is assessing a client with suspected dehydration. Which clinical
manifestation should the nurse prioritize as an indicator of fluid volume
deficit?
A. Increased urine output
B. Bounding pulse
C. Dry mucous membranes
D. Elevated blood pressure
Correct Answer: C. Dry mucous membranes
Rationale: Dry mucous membranes are a hallmark sign of dehydration
due to decreased fluid volume in the body, leading to reduced moisture in
mucosal tissues. Increased urine output (A) is not associated with dehy-
dration, as urine output typically decreases. A bounding pulse (B) is more
indicative of fluid overload or cardiovascular issues. Elevated blood pres-
sure (D) is not a primary sign of dehydration; hypotension is more common
due to reduced circulating volume.
Question 2: A client with a nasogastric tube reports nausea. What is the nurse’s first
action?
A. Administer an antiemetic medication
B. Check the tube for proper placement
C. Increase the suction pressure
D. Flush the tube with normal saline
Correct Answer: B. Check the tube for proper placement
Rationale: Nausea in a client with a nasogastric tube may indicate im-
proper placement, obstruction, or irritation. Verifying tube placement en-
sures it is in the stomach and not causing complications. Administering an
antiemetic (A) addresses the symptom but not the cause. Increasing suc-
tion pressure (C) could worsen irritation or cause tissue damage. Flushing
the tube (D) is appropriate after confirming placement.
Question 3: A nurse is preparing to administer a medication via intramuscular injec-
tion. Which site is most appropriate for an adult client?
A. Vastus lateralis
B. Deltoid
C. Ventrogluteal
D. Dorsogluteal
Correct Answer: C. Ventrogluteal
Rationale: The ventrogluteal site is preferred for intramuscular injections
in adults due to its large muscle mass, minimal nerve presence, and re-
duced risk of complications. The vastus lateralis (A) is suitable but less pre-
ferred for adults. The deltoid (B) has limited muscle mass for larger vol-
umes. The dorsogluteal site (D) is avoided due to the risk of sciatic nerve
injury.
1
,Question 4: When teaching a client about a low-sodium diet, which food should the
nurse recommend limiting?
A. Fresh apples
B. Canned soup
C. Grilled chicken
D. Brown rice
Correct Answer: B. Canned soup
Rationale: Canned soup is high in sodium due to preservatives, making it
a poor choice for a low-sodium diet. Fresh apples (A), grilled chicken (C),
and brown rice (D) are naturally low in sodium and suitable for the diet.
Question 5: A client with a history of heart failure is prescribed furosemide. Which
electrolyte imbalance should the nurse monitor for?
A. Hyperkalemia
B. Hypokalemia
C. Hypernatremia
D. Hypocalcemia
Correct Answer: B. Hypokalemia
Rationale: Furosemide, a loop diuretic, promotes potassium excretion, in-
creasing the risk of hypokalemia. Hyperkalemia (A) is less likely with di-
uretics. Hypernatremia (C) is not typically associated with furosemide, which
causes sodium loss. Hypocalcemia (D) is not a primary concern with this
medication.
Question 6: A nurse is caring for a client with a pressure injury. Which intervention
promotes wound healing?
A. Keeping the wound dry and uncovered
B. Applying a moist dressing
C. Massaging the surrounding tissue
D. Using a heat lamp on the wound
Correct Answer: B. Applying a moist dressing
Rationale: A moist environment supports wound healing by promoting
cell migration and preventing tissue dehydration. Keeping the wound dry
(A) delays healing. Massaging surrounding tissue (C) can cause further tis-
sue damage. Heat lamps (D) are not recommended due to the risk of burns.
Question 7: A client is receiving oxygen at 2 L/min via nasal cannula. What should the
nurse monitor to ensure safe oxygen administration?
A. Skin integrity around the cannula
B. Blood pressure every 4 hours
C. Urine output every shift
D. Room temperature
Correct Answer: A. Skin integrity around the cannula
Rationale: Prolonged use of a nasal cannula can cause skin breakdown
due to pressure and moisture. Blood pressure (B) and urine output (C) are
not directly related to oxygen administration. Room temperature (D) is less
critical than skin assessment.
Question 8: A nurse is teaching a client about proper body mechanics. Which statement
by the client indicates understanding?
2
, A. “I should bend at the waist to lift heavy objects.”
B. “I should keep objects close to my body when lifting.”
C. “I should twist my torso while carrying heavy loads.”
D. “I should lift with my arms fully extended.”
Correct Answer: B. I should keep objects close to my body when lifting.
Rationale: Keeping objects close to the body reduces strain on the back and
maintains balance. Bending at the waist (A) or twisting (C) increases injury
risk. Lifting with extended arms (D) strains muscles and joints.
Question 9: A client with diabetes mellitus reports feeling shaky and sweaty. What is
the nurse’s priority action?
A. Administer insulin
B. Check blood glucose level
C. Provide a high-protein snack
D. Encourage fluid intake
Correct Answer: B. Check blood glucose level
Rationale: Shaking and sweating suggest hypoglycemia. Checking blood
glucose confirms the diagnosis and guides treatment. Administering in-
sulin (A) could worsen hypoglycemia. A high-protein snack (C) is less effec-
tive than a fast-acting carbohydrate. Fluid intake (D) does not address the
immediate issue.
Question 10: A nurse is preparing to insert a urinary catheter. Which action ensures a
sterile technique?
A. Using clean gloves during insertion
B. Opening the sterile kit away from the body
C. Cleansing the meatus after catheter insertion
D. Holding the catheter with bare hands
Correct Answer: B. Opening the sterile kit away from the body
Rationale: Opening the sterile kit away from the body prevents contami-
nation of the sterile field. Clean gloves (A) are insufficient; sterile gloves are
required. Cleansing the meatus after insertion (C) is incorrect; it should be
done before. Holding the catheter with bare hands (D) breaks sterile tech-
nique.
Question 11: A client with chronic obstructive pulmonary disease (COPD) is receiving
oxygen therapy. Which position should the nurse recommend to improve
breathing?
A. Supine with head elevated
B. Prone with arms extended
C. Fowler’s position
D. Side-lying with knees bent
Correct Answer: C. Fowler’s position
Rationale: Fowler’s position (semi-upright) promotes lung expansion and
eases breathing in clients with COPD. Supine (A) may restrict lung expan-
sion. Prone (B) is uncomfortable and not ideal for breathing. Side-lying (D)
is less effective for respiratory distress.
Question 12: A nurse is assessing a client’s peripheral pulses. Which finding indicates a
normal pulse?
3
