HESI - Fundamentals LATEST 2026 EXAM
WITH AND CORRECT ANSWER WITH
RATIONALE / GRADED A+
The nurse is counting a client's respiratory rate. During a 30-
second interval, the nurse counts six respirations and the client
coughs three times. In repeating the count for a second 30-
second interval, the nurse counts eight respirations. Which
respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28 Correct Answer B
Rationale: The most accurate respiratory rate is the second count
obtained by the nurse, which was not interrupted by coughing.
Because it was counted for 30 seconds, the rate should be
doubled. Options A, C, and D are inaccurate recordings.
The nurse is teaching an obese client, newly diagnosed with
arteriosclerosis, about reducing the risk of a heart attack or
stroke. Which health promotion brochure is most important for the
nurse to provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You" Correct Answer C
Rationale: A health promotion brochure about decreasing
cholesterol is most important to provide this client, because the
most significant risk factor contributing to development of
arteriosclerosis is excess dietary fat, particularly saturated fat and
cholesterol. Option A does not address the underlying causes of
arteriosclerosis. Options B and D are also important factors for
,reversing arteriosclerosis but are not as important as lowering
cholesterol.
The nurse finds a client crying behind a locked bathroom door.
The client will not open the door. Which action should the nurse
implement first?
A. Instruct an unlicensed assistive personnel (UAP) to stay and
keep talking to the client.
B. Sit quietly in the client's room until the client leaves the
bathroom.
C. Allow the client to cry alone and leave the client in the
bathroom.
D. Talk to the client and attempt to find out why the client is
crying. Correct Answer D
Rationale: The nurse's first concern should be for the client's
safety, so an immediate assessment of the client's situation is
needed. Option A is incorrect; the nurse should implement the
intervention. The nurse may offer to stay nearby after first
assessing the situation more fully. Although option C may be
correct, the nurse should determine if the client's safety is
compromised and offer assistance, even if it is refused.
A client in a long-term care facility reports to the nurse that he has
not had a bowel movement in 2 days. Which intervention should
the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at
mealtimes.
B. Notify the health care provider and request a prescription for a
large-volume enema.
C. Assess the client's medical record to determine the client's
normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-
ounce glasses per day. Correct Answer C
Rationale: This client may not routinely have a daily bowel
movement, so the nurse should first assess this client's normal
,bowel habits before attempting any intervention. Option A, B, or D
may then be implemented, if warranted.
A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which
instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. Correct Answer B
Rationale: The most important teaching is to change positions
frequently because pressure is the most significant factor related
to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce
further risk. Option D is an intervention of last resort because this
will be very expensive for the client.
Urinary catheterization is prescribed for a postoperative female
client who has been unable to void for 8 hours. The nurse inserts
the catheter, but no urine is seen in the tubing. Which action will
the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another
catheter.
D. Notify the health care provider of a possible obstruction.
Correct Answer C
Rationale: It is likely that the first catheter is in the vagina, rather
than the bladder. Leaving the first catheter in place will help locate
the meatus when attempting the second catheterization. The
client should have at least 240 mL of urine after 8 hours. Option A
does not resolve the problem. Option B will not change the
location of the catheter unless it is completely removed, in which
case a new catheter must be used. There is no evidence of a
urinary tract obstruction if the catheter could be easily inserted.
, The mental health nurse plans to discuss a client's depression
with the health care provider in the emergency department. There
are two clients sitting across from the emergency department
desk. Which nursing action is best?
A. Only refer to the client by gender.
B. Identify the client only by age.
C. Avoid using the client's name.
D. Discuss the client another time. Correct Answer D
Rationale: The best nursing action is to discuss the client another
time. Confidentiality must be observed at all times, so the nurse
should not discuss the client when the conversation can be
overheard by others. Details can identify the client when referring
to the client by gender or age, even when not using the client's
name.
The nurse is teaching a client how to perform progressive muscle
relaxation techniques to relieve insomnia. A week later the client
reports that he is still unable to sleep, despite following the same
routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is
achieved.
D. Ask the client to describe the routine he is currently following.
Correct Answer D
Rationale: The nurse should first evaluate whether the client has
been adhering to the original instructions. A verbal report of the
client's routine will provide more specific information than the
client's written diary. The nurse can then determine which
changes need to be made. The routine practiced by the client is
clearly unsuccessful, so encouragement alone is insufficient.
WITH AND CORRECT ANSWER WITH
RATIONALE / GRADED A+
The nurse is counting a client's respiratory rate. During a 30-
second interval, the nurse counts six respirations and the client
coughs three times. In repeating the count for a second 30-
second interval, the nurse counts eight respirations. Which
respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28 Correct Answer B
Rationale: The most accurate respiratory rate is the second count
obtained by the nurse, which was not interrupted by coughing.
Because it was counted for 30 seconds, the rate should be
doubled. Options A, C, and D are inaccurate recordings.
The nurse is teaching an obese client, newly diagnosed with
arteriosclerosis, about reducing the risk of a heart attack or
stroke. Which health promotion brochure is most important for the
nurse to provide to this client?
A. "Monitoring Your Blood Pressure at Home"
B. "Smoking Cessation as a Lifelong Commitment"
C. "Decreasing Cholesterol Levels Through Diet"
D. "Stress Management for a Healthier You" Correct Answer C
Rationale: A health promotion brochure about decreasing
cholesterol is most important to provide this client, because the
most significant risk factor contributing to development of
arteriosclerosis is excess dietary fat, particularly saturated fat and
cholesterol. Option A does not address the underlying causes of
arteriosclerosis. Options B and D are also important factors for
,reversing arteriosclerosis but are not as important as lowering
cholesterol.
The nurse finds a client crying behind a locked bathroom door.
The client will not open the door. Which action should the nurse
implement first?
A. Instruct an unlicensed assistive personnel (UAP) to stay and
keep talking to the client.
B. Sit quietly in the client's room until the client leaves the
bathroom.
C. Allow the client to cry alone and leave the client in the
bathroom.
D. Talk to the client and attempt to find out why the client is
crying. Correct Answer D
Rationale: The nurse's first concern should be for the client's
safety, so an immediate assessment of the client's situation is
needed. Option A is incorrect; the nurse should implement the
intervention. The nurse may offer to stay nearby after first
assessing the situation more fully. Although option C may be
correct, the nurse should determine if the client's safety is
compromised and offer assistance, even if it is refused.
A client in a long-term care facility reports to the nurse that he has
not had a bowel movement in 2 days. Which intervention should
the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at
mealtimes.
B. Notify the health care provider and request a prescription for a
large-volume enema.
C. Assess the client's medical record to determine the client's
normal bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-
ounce glasses per day. Correct Answer C
Rationale: This client may not routinely have a daily bowel
movement, so the nurse should first assess this client's normal
,bowel habits before attempting any intervention. Option A, B, or D
may then be implemented, if warranted.
A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which
instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. Correct Answer B
Rationale: The most important teaching is to change positions
frequently because pressure is the most significant factor related
to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce
further risk. Option D is an intervention of last resort because this
will be very expensive for the client.
Urinary catheterization is prescribed for a postoperative female
client who has been unable to void for 8 hours. The nurse inserts
the catheter, but no urine is seen in the tubing. Which action will
the nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another
catheter.
D. Notify the health care provider of a possible obstruction.
Correct Answer C
Rationale: It is likely that the first catheter is in the vagina, rather
than the bladder. Leaving the first catheter in place will help locate
the meatus when attempting the second catheterization. The
client should have at least 240 mL of urine after 8 hours. Option A
does not resolve the problem. Option B will not change the
location of the catheter unless it is completely removed, in which
case a new catheter must be used. There is no evidence of a
urinary tract obstruction if the catheter could be easily inserted.
, The mental health nurse plans to discuss a client's depression
with the health care provider in the emergency department. There
are two clients sitting across from the emergency department
desk. Which nursing action is best?
A. Only refer to the client by gender.
B. Identify the client only by age.
C. Avoid using the client's name.
D. Discuss the client another time. Correct Answer D
Rationale: The best nursing action is to discuss the client another
time. Confidentiality must be observed at all times, so the nurse
should not discuss the client when the conversation can be
overheard by others. Details can identify the client when referring
to the client by gender or age, even when not using the client's
name.
The nurse is teaching a client how to perform progressive muscle
relaxation techniques to relieve insomnia. A week later the client
reports that he is still unable to sleep, despite following the same
routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is
achieved.
D. Ask the client to describe the routine he is currently following.
Correct Answer D
Rationale: The nurse should first evaluate whether the client has
been adhering to the original instructions. A verbal report of the
client's routine will provide more specific information than the
client's written diary. The nurse can then determine which
changes need to be made. The routine practiced by the client is
clearly unsuccessful, so encouragement alone is insufficient.
