HESI Fundamentals RN
Exam 2025/2026 – Verified
Correct Answers & Full
Rationales | Real Exam
1. A nurse is preparing to administer a medication via intramuscular injection.
Which action ensures client safety?
A. Inject without aspirating
B. Aspirate before injecting
C. Use a 25-gauge needle
D. Inject at a 45-degree angle
Rationale: Aspirating before IM injection ensures the needle is not in a blood vessel, preventing
medication entry into the bloodstream (TJC 2025). A 21–23-gauge needle is standard for IM; a
90-degree angle is used. Prioritization ensures safe administration.
2. A nurse is assisting a client with ambulation post-surgery. Which intervention
promotes safety?
A. Allow client to walk independently
B. Use a gait belt
C. Provide slippers without traction
D. Ambulate without assistive devices
Rationale: A gait belt prevents falls by providing support during ambulation, a priority for post-
surgical clients (ANA 2025). Non-skid footwear and assistive devices enhance safety;
independence is encouraged only when stable.
3. A nurse is performing hand hygiene. What is the minimum duration for
effective handwashing?
,A. 10 seconds
B. 20 seconds
C. 5 seconds
D. 40 seconds
Rationale: Handwashing for ≥20 seconds with soap reduces pathogen transmission (CDC 2025).
Infection control is a priority; shorter durations are ineffective, while longer may be unnecessary.
4. A nurse is positioning a client with a recent stroke to prevent pressure ulcers.
Which position is best?
A. Supine with head flat
B. Side-lying with pillows
C. Prone position
D. Trendelenburg
Rationale: Side-lying with pillows offloads pressure points (e.g., sacrum), reducing ulcer risk
(NPUAP 2025). Repositioning every 2 hours and skin assessments prioritize client safety and
skin integrity.
5. A nurse is teaching a client about a low-sodium diet. Which food should be
avoided?
A. Fresh vegetables
B. Canned soup
C. Whole grains
D. Fresh fruit
Rationale: Canned soup is high in sodium (>500 mg/serving), risking fluid retention (AHA
2025). Nutrition teaching prioritizes fresh, unprocessed foods to support client health and
compliance.
6. A nurse is assisting a client with a bedpan. Which action ensures client
comfort?
A. Place bedpan with client supine
B. Elevate head of bed 30 degrees
C. Use a cold bedpan
D. Remove bedpan immediately after use
,Rationale: Elevating the head of bed 30 degrees mimics natural positioning for elimination,
enhancing comfort and privacy (ANA 2025). A warm bedpan and timely removal further
prioritize client dignity.
7. A nurse is preparing to insert a urinary catheter. Which action prevents
infection?
A. Use clean gloves
B. Use sterile technique
C. Clean with soap only
D. Leave catheter open to air
Rationale: Sterile technique during catheter insertion minimizes CAUTI risk (CDC 2025).
Infection control is a priority; teaching includes monitoring for cloudy urine or fever.
8. A nurse is caring for a client with a new tracheostomy. Which suctioning
practice is correct?
A. Suction for 20 seconds
B. Use sterile saline
C. Apply suction while inserting
D. Suction every hour
Rationale: Sterile saline maintains catheter sterility during tracheostomy suctioning, preventing
infection (AACN 2025). Suctioning is ≤10 seconds as needed; prioritizing airway patency
ensures safety.
9. A nurse is transferring a client from bed to wheelchair. Which action ensures
safety?
A. Lock bed only
B. Lock bed and wheelchair
C. Use one staff member
D. Keep brakes off
Rationale: Locking both bed and wheelchair prevents movement, reducing fall risk (TJC 2025).
Two-person assistance may be needed; prioritization ensures client safety during transfers.
, 10. A nurse is teaching a client about safe medication storage. Which instruction
is priority?
A. Store in bathroom cabinet
B. Keep out of reach of children
C. Store in refrigerator door
D. Keep in original packaging
Rationale: Keeping medications out of children’s reach prevents accidental ingestion, a priority
for safety (AAP 2025). Teaching includes using lockboxes; storage conditions vary by
medication.
11. A nurse is assessing a client’s peripheral IV site. Which finding requires
immediate action?
A. Cool skin around site
B. Redness and swelling
C. Clear fluid infusion
D. Secure dressing
Rationale: Redness and swelling indicate phlebitis or infiltration, risking tissue damage (INS
2025). Immediate discontinuation and assessment prioritize client safety; teaching monitors for
infection.
12. A nurse is assisting a client with oral hygiene. Which action is appropriate for
an unconscious client?
A. Use a toothbrush
B. Use foam swabs
C. Provide mouthwash
D. Skip oral care
Rationale: Foam swabs safely clean the oral cavity in unconscious clients, preventing aspiration
(ANA 2025). Oral care every 2–4 hours prioritizes infection prevention and comfort.
13. A nurse is preparing a sterile field. Which action maintains sterility?
A. Reach over the field
B. Keep objects 1 inch from edges
Exam 2025/2026 – Verified
Correct Answers & Full
Rationales | Real Exam
1. A nurse is preparing to administer a medication via intramuscular injection.
Which action ensures client safety?
A. Inject without aspirating
B. Aspirate before injecting
C. Use a 25-gauge needle
D. Inject at a 45-degree angle
Rationale: Aspirating before IM injection ensures the needle is not in a blood vessel, preventing
medication entry into the bloodstream (TJC 2025). A 21–23-gauge needle is standard for IM; a
90-degree angle is used. Prioritization ensures safe administration.
2. A nurse is assisting a client with ambulation post-surgery. Which intervention
promotes safety?
A. Allow client to walk independently
B. Use a gait belt
C. Provide slippers without traction
D. Ambulate without assistive devices
Rationale: A gait belt prevents falls by providing support during ambulation, a priority for post-
surgical clients (ANA 2025). Non-skid footwear and assistive devices enhance safety;
independence is encouraged only when stable.
3. A nurse is performing hand hygiene. What is the minimum duration for
effective handwashing?
,A. 10 seconds
B. 20 seconds
C. 5 seconds
D. 40 seconds
Rationale: Handwashing for ≥20 seconds with soap reduces pathogen transmission (CDC 2025).
Infection control is a priority; shorter durations are ineffective, while longer may be unnecessary.
4. A nurse is positioning a client with a recent stroke to prevent pressure ulcers.
Which position is best?
A. Supine with head flat
B. Side-lying with pillows
C. Prone position
D. Trendelenburg
Rationale: Side-lying with pillows offloads pressure points (e.g., sacrum), reducing ulcer risk
(NPUAP 2025). Repositioning every 2 hours and skin assessments prioritize client safety and
skin integrity.
5. A nurse is teaching a client about a low-sodium diet. Which food should be
avoided?
A. Fresh vegetables
B. Canned soup
C. Whole grains
D. Fresh fruit
Rationale: Canned soup is high in sodium (>500 mg/serving), risking fluid retention (AHA
2025). Nutrition teaching prioritizes fresh, unprocessed foods to support client health and
compliance.
6. A nurse is assisting a client with a bedpan. Which action ensures client
comfort?
A. Place bedpan with client supine
B. Elevate head of bed 30 degrees
C. Use a cold bedpan
D. Remove bedpan immediately after use
,Rationale: Elevating the head of bed 30 degrees mimics natural positioning for elimination,
enhancing comfort and privacy (ANA 2025). A warm bedpan and timely removal further
prioritize client dignity.
7. A nurse is preparing to insert a urinary catheter. Which action prevents
infection?
A. Use clean gloves
B. Use sterile technique
C. Clean with soap only
D. Leave catheter open to air
Rationale: Sterile technique during catheter insertion minimizes CAUTI risk (CDC 2025).
Infection control is a priority; teaching includes monitoring for cloudy urine or fever.
8. A nurse is caring for a client with a new tracheostomy. Which suctioning
practice is correct?
A. Suction for 20 seconds
B. Use sterile saline
C. Apply suction while inserting
D. Suction every hour
Rationale: Sterile saline maintains catheter sterility during tracheostomy suctioning, preventing
infection (AACN 2025). Suctioning is ≤10 seconds as needed; prioritizing airway patency
ensures safety.
9. A nurse is transferring a client from bed to wheelchair. Which action ensures
safety?
A. Lock bed only
B. Lock bed and wheelchair
C. Use one staff member
D. Keep brakes off
Rationale: Locking both bed and wheelchair prevents movement, reducing fall risk (TJC 2025).
Two-person assistance may be needed; prioritization ensures client safety during transfers.
, 10. A nurse is teaching a client about safe medication storage. Which instruction
is priority?
A. Store in bathroom cabinet
B. Keep out of reach of children
C. Store in refrigerator door
D. Keep in original packaging
Rationale: Keeping medications out of children’s reach prevents accidental ingestion, a priority
for safety (AAP 2025). Teaching includes using lockboxes; storage conditions vary by
medication.
11. A nurse is assessing a client’s peripheral IV site. Which finding requires
immediate action?
A. Cool skin around site
B. Redness and swelling
C. Clear fluid infusion
D. Secure dressing
Rationale: Redness and swelling indicate phlebitis or infiltration, risking tissue damage (INS
2025). Immediate discontinuation and assessment prioritize client safety; teaching monitors for
infection.
12. A nurse is assisting a client with oral hygiene. Which action is appropriate for
an unconscious client?
A. Use a toothbrush
B. Use foam swabs
C. Provide mouthwash
D. Skip oral care
Rationale: Foam swabs safely clean the oral cavity in unconscious clients, preventing aspiration
(ANA 2025). Oral care every 2–4 hours prioritizes infection prevention and comfort.
13. A nurse is preparing a sterile field. Which action maintains sterility?
A. Reach over the field
B. Keep objects 1 inch from edges
