HESI Fundamentals Exam Practice
Questions
The nurse is preparing a male client who has an indwelling catheter and an IV infusion to
ambulate from the bed to a chair for the first time following abdominal surgery. What action(s)
should the nurse implement prior to assisting the client to the chair? (Select all that apply.)
A) Pre-medicate the client with an analgesic
B) Inform the client of the plan for moving to the chair
C) Obtain and place a portable commode by the bed.
D) Ask the client to push the IV pole to the chair.
E) Clamp the indwelling catheter.
F) Assess the client's blood pressure. - ✔✔A,B,D,F
Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and
maximizes compliance. To ensure the client's cooperation and promote independence, the
nurse should inform the client about the plan for moving to the chair (B) and encourage the
client to participate by pushing the IV pole when walking to the chair (D). The nurse should
assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic
hypotension. (C and E) are not indicated.
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a
light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to
use first?
A) Hydrogel.
B) Exudate absorber.
C) Wet to moist dressing.
D) Transparent adhesive film - ✔✔C
,To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet
to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the
prepared wound bed to prevent further damage of granulating any surrounding tissue.
Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it
does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide
a moist wound surface, absorb exudate, and support debridement, but do not prepare the
wound bed for proper healing. Transparent dressings (D) are used to protect against
contamination and friction while maintaining a clean moist surface.
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
What action should the nurse take after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution. - ✔✔B
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the
irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid
instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied
(A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can
be subtracted from the output at that time.
While caring for a child and mother from Cambodia, what action should the nurse implement to
accommodate the clients' cultural needs?
A) Speak initially with the oldest family member to show respect.
B) Realize that Southeast Asians may not take Western medications.
C) Ask the husband to step out during the mother's pelvic examination.
D) Tell the family that planning health care is provided in private with the client. - ✔✔A
,Members of the Asian culture have high respect for others, especially those in positions of
authority. Extended family members need to be included in the nursing care plan (A). Southeast
Asians do not necessarily refuse Western medications (B). Asians also believe that touching
strangers is not acceptable, particularly health professionals whom they have not previously
known, so the husband should be allowed to remain with his wife during the pelvic exam (C).
Provided that the presence of other family members is not harmful to the client's well-being,
(D) is not correct.
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. - ✔✔C
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.
The charge nurse assigns a nursing procedure to a new staff nurse who has not previously
performed the procedure. What action is most important for the new staff nurse to take?
A) Review the steps in the procedure manual.
B) Ask another nurse to assist while implementing the procedure.
C) Follow the agency's policy and procedure.
D) Refuse to perform the task that is beyond the nurse's experience. - ✔✔D
, According to states' nurse practice acts, it is the responsibility of the nurse to function within
the scope of competency (D), and in this case safe nursing practice constitutes refusal to
perform the procedure because of a lack of experience. Although state mandates, agency
policies, and continued education and experience identify tasks that are within the scope of
nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency,
and then pursue opportunities to enhance their competency (A, B, and C).
A male client with venous incompetence stands up and his blood pressure subsequently drops.
Which finding should the nurse identify as a compensatory response?
A) Bradycardia.
B) Increase in pulse rate.
C) Peripheral vasodilation.
D) Increase in cardiac output. - ✔✔B
When postural hypotension occurs, the body attempts to restore arterial pressure by
stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral
vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence
through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs
when orthostatic hypotension occurs.
A client with Raynaud's disease asks the nurse about using biofeedback for self-management of
symptoms. What response is best for the nurse to provide?
A) The responses to biofeedback have not been well established and may be a waste of time
and money.
B) Biofeedback requires extensive training to retrain voluntary muscles, not involuntary
responses.
C) Although biofeedback is easily learned, it is most often used to manage exacerbation of
symptoms.
D) Biofeedback allows the client to control involuntary responses to promote peripheral
vasodilation. - ✔✔D
Questions
The nurse is preparing a male client who has an indwelling catheter and an IV infusion to
ambulate from the bed to a chair for the first time following abdominal surgery. What action(s)
should the nurse implement prior to assisting the client to the chair? (Select all that apply.)
A) Pre-medicate the client with an analgesic
B) Inform the client of the plan for moving to the chair
C) Obtain and place a portable commode by the bed.
D) Ask the client to push the IV pole to the chair.
E) Clamp the indwelling catheter.
F) Assess the client's blood pressure. - ✔✔A,B,D,F
Pre-medicating the client with an analgesic (A) reduces the client's pain during mobilization and
maximizes compliance. To ensure the client's cooperation and promote independence, the
nurse should inform the client about the plan for moving to the chair (B) and encourage the
client to participate by pushing the IV pole when walking to the chair (D). The nurse should
assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic
hypotension. (C and E) are not indicated.
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a
light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to
use first?
A) Hydrogel.
B) Exudate absorber.
C) Wet to moist dressing.
D) Transparent adhesive film - ✔✔C
,To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet
to moist dressings (C), which are discontinued and then a hydrogel alginate can be placed in the
prepared wound bed to prevent further damage of granulating any surrounding tissue.
Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it
does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide
a moist wound surface, absorb exudate, and support debridement, but do not prepare the
wound bed for proper healing. Transparent dressings (D) are used to protect against
contamination and friction while maintaining a clean moist surface.
The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
What action should the nurse take after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution. - ✔✔B
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the
irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid
instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied
(A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can
be subtracted from the output at that time.
While caring for a child and mother from Cambodia, what action should the nurse implement to
accommodate the clients' cultural needs?
A) Speak initially with the oldest family member to show respect.
B) Realize that Southeast Asians may not take Western medications.
C) Ask the husband to step out during the mother's pelvic examination.
D) Tell the family that planning health care is provided in private with the client. - ✔✔A
,Members of the Asian culture have high respect for others, especially those in positions of
authority. Extended family members need to be included in the nursing care plan (A). Southeast
Asians do not necessarily refuse Western medications (B). Asians also believe that touching
strangers is not acceptable, particularly health professionals whom they have not previously
known, so the husband should be allowed to remain with his wife during the pelvic exam (C).
Provided that the presence of other family members is not harmful to the client's well-being,
(D) is not correct.
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. - ✔✔C
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.
The charge nurse assigns a nursing procedure to a new staff nurse who has not previously
performed the procedure. What action is most important for the new staff nurse to take?
A) Review the steps in the procedure manual.
B) Ask another nurse to assist while implementing the procedure.
C) Follow the agency's policy and procedure.
D) Refuse to perform the task that is beyond the nurse's experience. - ✔✔D
, According to states' nurse practice acts, it is the responsibility of the nurse to function within
the scope of competency (D), and in this case safe nursing practice constitutes refusal to
perform the procedure because of a lack of experience. Although state mandates, agency
policies, and continued education and experience identify tasks that are within the scope of
nursing practice, nurses should first refuse to perform tasks that are beyond their proficiency,
and then pursue opportunities to enhance their competency (A, B, and C).
A male client with venous incompetence stands up and his blood pressure subsequently drops.
Which finding should the nurse identify as a compensatory response?
A) Bradycardia.
B) Increase in pulse rate.
C) Peripheral vasodilation.
D) Increase in cardiac output. - ✔✔B
When postural hypotension occurs, the body attempts to restore arterial pressure by
stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral
vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence
through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs
when orthostatic hypotension occurs.
A client with Raynaud's disease asks the nurse about using biofeedback for self-management of
symptoms. What response is best for the nurse to provide?
A) The responses to biofeedback have not been well established and may be a waste of time
and money.
B) Biofeedback requires extensive training to retrain voluntary muscles, not involuntary
responses.
C) Although biofeedback is easily learned, it is most often used to manage exacerbation of
symptoms.
D) Biofeedback allows the client to control involuntary responses to promote peripheral
vasodilation. - ✔✔D
