NIGHTINGALE COLLEGE ACTUAL H.E.S.I FUNDAMENTALS
V.2 2025 COMPLETE QUESTION AND ANSWER ORIGINAL
ALREADY GRADE A
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I
have cancer and do not have long to live." Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
D) "Yes, your condition is serious."
When performing blood pressure measurement to assess for orthostatic hypotension, which
action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside.
C) Position the client supine for a few minutes.
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a
client who is unconscious. After supporting the client's knee with one hand, what action
should the nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel.
D) Cradle the client's heel.
,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) Draw up the irrigating solution into the syringe.
Which client care requires the nurse to wear barrier gloves as required by the protocol for
Standard Precautions?
A) Removing the empty food tray from a client with a urinary catheter.
B) Washing and combing the hair of a client with a fractured leg in traction.
C) Administering oral medications to a cooperative client with a wound infection.
D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
What action should the nurse implement to prevent the formation of a sacral ulcer for a
client who is immobile?
A) Maintain in a lateral position using protective wrist and vest devices.
B) Position prone with a small pillow below the diaphragm.
C) Raise the head and knee gatch when lying in a supine position.
D) Transfer into a wheelchair close to the nurse's station for observation.
B) Position prone with a small pillow below the diaphragm.
At 0100 on a male client's second postoperative night, the client states he is unstable to sleep
and plans to read until feeling sleepy. What action should the nurse implement?
A) Leave the room and close the door to the client's room.
B) Assess the appearance of the client's surgical dressing.
C) Bring the client a prescribed PRN sedative-hypnotic.
D) Discuss symptoms of sleep deprivation with the client.
C) Bring the client a prescribed PRN sedative-hypnotic.
,The nursing staff in the cardiovascular intensive care unit are creating a continuous quality
improvement project on social media that addresses coronary artery disease (CAD). Which
action should the nurse implement to protect client privacy?
A) Remove identifying information of the clients who participated.
B) Recall that authored content may be legally discoverable.
C) Share material from credible, peer reviewed sources only.
D) Respect all copyright laws when adding website content.
A) Remove identifying information of the clients who participated.
.
The home health nurse is reviewing the personal care of an elderly client who lives alone.
Which client assessment findings indicate the need to assign unlicensed assistive personnel
(UAP) to provide routine foot care and file the client's toenails? Select all that apply.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client's risk for infection related to
the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
B) Encourage increased intake of oral fluids.
, To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
C) Ask the client to describe the pain.
A male client with unstable angina needs a cardiac catheterization, so the healthcare provider
explains the risks and benefits of the procedure, and then leaves to set up for the procedure.
When the nurse presents the consent form for signature, the client hesitates and asks how
the wires will keep his heart going. Which action should the nurse take?
A) Answer the client's specific questions with a short understandable explanation.
B) Postpone the procedure until the client understands the risks and benefits.
C) Call the client's next of kin and ask them to provide verbal consent.
D) Page the healthcare provider to return and provide additional explanation.
B) Postpone the procedure until the client understands the risks and benefits.
The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise
the hinge joints, which action should the nurse instruct the client to perform?
A) Tilt the pelvis forwards and backwards.
B) Bend the arm by flexing the ulnar to the humerus.
C) Turn the head to the right and left.
D) Extend the arm at the side and rotate in circles.
B) Bend the arm by flexing the ulnar to the humerus.
A postoperative client has three different PRN analgesics prescribed for different levels of
pain. The nurse inadvertently administers a dose that is not within the prescribed
parameters. What actions should the nurse take first?
A) Assess for side effects of the medication.
B) Document the client's responses.
C) Complete a medication error report.
D) Determine if the pain was relieved.
A) Assess for side effects of the medication.
V.2 2025 COMPLETE QUESTION AND ANSWER ORIGINAL
ALREADY GRADE A
A client who has been diagnosed with terminal cancer tells the nurse, "The doctor told me I
have cancer and do not have long to live." Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
D) "Yes, your condition is serious."
When performing blood pressure measurement to assess for orthostatic hypotension, which
action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside.
C) Position the client supine for a few minutes.
The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a
client who is unconscious. After supporting the client's knee with one hand, what action
should the nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel.
D) Cradle the client's heel.
,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) Draw up the irrigating solution into the syringe.
Which client care requires the nurse to wear barrier gloves as required by the protocol for
Standard Precautions?
A) Removing the empty food tray from a client with a urinary catheter.
B) Washing and combing the hair of a client with a fractured leg in traction.
C) Administering oral medications to a cooperative client with a wound infection.
D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
D) Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
What action should the nurse implement to prevent the formation of a sacral ulcer for a
client who is immobile?
A) Maintain in a lateral position using protective wrist and vest devices.
B) Position prone with a small pillow below the diaphragm.
C) Raise the head and knee gatch when lying in a supine position.
D) Transfer into a wheelchair close to the nurse's station for observation.
B) Position prone with a small pillow below the diaphragm.
At 0100 on a male client's second postoperative night, the client states he is unstable to sleep
and plans to read until feeling sleepy. What action should the nurse implement?
A) Leave the room and close the door to the client's room.
B) Assess the appearance of the client's surgical dressing.
C) Bring the client a prescribed PRN sedative-hypnotic.
D) Discuss symptoms of sleep deprivation with the client.
C) Bring the client a prescribed PRN sedative-hypnotic.
,The nursing staff in the cardiovascular intensive care unit are creating a continuous quality
improvement project on social media that addresses coronary artery disease (CAD). Which
action should the nurse implement to protect client privacy?
A) Remove identifying information of the clients who participated.
B) Recall that authored content may be legally discoverable.
C) Share material from credible, peer reviewed sources only.
D) Respect all copyright laws when adding website content.
A) Remove identifying information of the clients who participated.
.
The home health nurse is reviewing the personal care of an elderly client who lives alone.
Which client assessment findings indicate the need to assign unlicensed assistive personnel
(UAP) to provide routine foot care and file the client's toenails? Select all that apply.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client's risk for infection related to
the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
B) Encourage increased intake of oral fluids.
, To assess the quality of an adult client's pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
C) Ask the client to describe the pain.
A male client with unstable angina needs a cardiac catheterization, so the healthcare provider
explains the risks and benefits of the procedure, and then leaves to set up for the procedure.
When the nurse presents the consent form for signature, the client hesitates and asks how
the wires will keep his heart going. Which action should the nurse take?
A) Answer the client's specific questions with a short understandable explanation.
B) Postpone the procedure until the client understands the risks and benefits.
C) Call the client's next of kin and ask them to provide verbal consent.
D) Page the healthcare provider to return and provide additional explanation.
B) Postpone the procedure until the client understands the risks and benefits.
The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise
the hinge joints, which action should the nurse instruct the client to perform?
A) Tilt the pelvis forwards and backwards.
B) Bend the arm by flexing the ulnar to the humerus.
C) Turn the head to the right and left.
D) Extend the arm at the side and rotate in circles.
B) Bend the arm by flexing the ulnar to the humerus.
A postoperative client has three different PRN analgesics prescribed for different levels of
pain. The nurse inadvertently administers a dose that is not within the prescribed
parameters. What actions should the nurse take first?
A) Assess for side effects of the medication.
B) Document the client's responses.
C) Complete a medication error report.
D) Determine if the pain was relieved.
A) Assess for side effects of the medication.
