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. - (answer) 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. - (answer) 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?
,NURSING HESI FUNDAMENTALS EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 100 QUESTIONS
AND CORRECT DETAILED ANSWERS
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. - (answer) 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? - (answer) 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.
,NURSING HESI FUNDAMENTALS EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 100 QUESTIONS
AND CORRECT DETAILED ANSWERS
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. - (answer) 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. - (answer) 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. - (answer) 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.
, NURSING HESI FUNDAMENTALS EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 100 QUESTIONS
AND CORRECT DETAILED ANSWERS
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. - (answer) 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.
C) Encourage the client to make future plans, even if they are unrealistic.
D) Instruct the client's family to focus on positive aspects of the client's life. - (answer) Answer: B
Rationale
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help
the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a
family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the
client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B).
A male client with venous incompetence stands up and his blood pressure subsequently drops. Which
finding should the nurse identify as a compensatory response?
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. - (answer) 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. - (answer) 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?
,NURSING HESI FUNDAMENTALS EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 100 QUESTIONS
AND CORRECT DETAILED ANSWERS
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. - (answer) 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? - (answer) 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.
,NURSING HESI FUNDAMENTALS EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 100 QUESTIONS
AND CORRECT DETAILED ANSWERS
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. - (answer) 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. - (answer) 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. - (answer) 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.
, NURSING HESI FUNDAMENTALS EXAM NEWEST 2024-2025 ACTUAL EXAM COMPLETE 100 QUESTIONS
AND CORRECT DETAILED ANSWERS
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. - (answer) 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.
C) Encourage the client to make future plans, even if they are unrealistic.
D) Instruct the client's family to focus on positive aspects of the client's life. - (answer) Answer: B
Rationale
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help
the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a
family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the
client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B).
A male client with venous incompetence stands up and his blood pressure subsequently drops. Which
finding should the nurse identify as a compensatory response?
