HESI FUNDAMENTALS LATEST 2026
EXAM WITH QUESTION AND
VERIFIED ANSWER / GRADED A+
A client's infusion of normal saline infiltrated earlier today, and
approximately 500 mL of saline infused into the subcutaneous
tissue. The client is now complaining of excruciating arm pain and
demanding stronger pain medications. What initial action is most
important for the nurse to take?
A. Ask about any past history of drug abuse or addiction.
B. Measure the pulse volume and capillary refill distal to the
infiltration.
C. Compress the infiltrated tissue to measure the degree of
edema.
D. Evaluate the extent of ecchymosis over the forearm area.
Correct Answer B. Measure the pulse volume and capillary refill
distal to the infiltration. (Pain and diminished pulse volume (B) are
signs of compartment syndrome, which can progress to complete
loss of the peripheral pulse in the extremity. Compartment
syndrome occurs when external pressure (usually from a cast) or
internal pressure (usually form subcutaneous infused fluid),
exceeds capillary perfusion pressure resulting in decreased blood
flow to the extremity. (A) should not be pursued until physical
causes of the pain are ruled out. (C) is less of a priority than
determining the effects of the edema on circulation and nerve
function. Further assessment of the client's ecchymosis can be
delayed until the signs of edema and compression that suggest
compartment syndrome have been examined (D).)
,The nurse assigns a UAP to obtain vital signs from a very anxious
client. What instructions should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the
chart.
B. Notify the medication nurse immediately if the pulse or blood
pressure is low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. Correct
Answer C. Report the results of the vital signs to the nurse.
(Interpretation of the vital signs is the responsibility of the nurse,
so the UAP should report vital sign measurements of to the nurse
(C). (A, B, and D) require the UAP to interpret the vital signs,
which is beyond the scope of the UAP's authority.)
Twenty minutes after beginning a heat application, the client
states that the heating pad no longer feels warm enough. What is
the best response by the nurse?
A. That means you have derived the maximum benefit, and the
heat can be removed.
B. Your blood vessels are becoming dilated and removing the
heat from the site.
C. We will increase the temperature 5 degrees when the pad no
longer feels warm.
D. The body's receptors adapt over time as they are exposed to
heat. Correct Answer D. "The body's receptors adapt over time as
they are exposed to heat."
( (D) describes thermal adaptation, which occurs 20 to 30 minutes
after heat application. (A and B) provide false information. (C) is
not based on knowledge of physiology and is unsafe action that
may harm the client.)
When assessing a client with wrist restraints, the nurse observes
that the fingers on the right hand are blue. What action should the
nurse implement first?
A. Loosen the right wrist restraint.
,B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. Correct Answer A. Loosen the
right wrist restraint.
(The priority nursing action is to restore circulation by loosening
the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry
(B) measures saturation of hemoglobin with oxygen and is not
indicated in situations where the cyanosis is related to mechanical
compression-- the restraints.)
An elderly client who requires frequent monitoring fell and
fractured a hip. Which nurse is at greatest risk for a malpractice
judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote
poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at
the time of the fall.
C. The nurse who transferred the client to the chair when the fall
occurred.
D. The charge nurse who completed rounds 30 minutes before
the fall occurred. Correct Answer C. The nurse who transferred
the client to the chair when the fall occurred.
(The four elements of malpractice are: breach of duty owed,
failure to adhere to the recognized standard of care, direct
causation of injury, and evidence of actual injury. The hip fracture
is the actual injury and the standard of care was "frequent
monitoring." (C) implies the duty was owed and the injury
occurred while the nurse was in charge of the client's care. There
is no evidence of negligence in (A, B, and D). )
The nurse observes an unlicensed assistive personnel (UAP)
taking a client's blood pressure with a cuff that is too small, but
, the blood pressure reading obtained is within the client's usual
range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled
assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood
pressure. Correct Answer B. Reassess the client's blood pressure
using a larger cuff.
(The most important action is to ensure that an accurate BP
reading is obtained. The nurse should reassess the BP with the
correct size cuff (B). Reassessment should not be postponed (A).
Though (C and D) are likely indicated, these actions do not have
the priority of (B).)
An elderly client with a fractured left hip is on strict bedrest. Which
nursing measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
Correct Answer D. Gently life the client when moving into a
desired position.
(To avoid shearing forces when repositioning, the client should be
lifted gently across a surface (D). Reddened areas should NOT
be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active
range of motion (B) may be limited on the affected leg. The
position described in (C) is contraindicated for a client with a
fractured left hip.)
The UAPs working on a chronic neuro unit ask the nurse to help
them determine the safest way to transfer an elderly client w/ left-
sided weakness from the bed to the chair. What method
describes the correct transfer procedure for this client?
EXAM WITH QUESTION AND
VERIFIED ANSWER / GRADED A+
A client's infusion of normal saline infiltrated earlier today, and
approximately 500 mL of saline infused into the subcutaneous
tissue. The client is now complaining of excruciating arm pain and
demanding stronger pain medications. What initial action is most
important for the nurse to take?
A. Ask about any past history of drug abuse or addiction.
B. Measure the pulse volume and capillary refill distal to the
infiltration.
C. Compress the infiltrated tissue to measure the degree of
edema.
D. Evaluate the extent of ecchymosis over the forearm area.
Correct Answer B. Measure the pulse volume and capillary refill
distal to the infiltration. (Pain and diminished pulse volume (B) are
signs of compartment syndrome, which can progress to complete
loss of the peripheral pulse in the extremity. Compartment
syndrome occurs when external pressure (usually from a cast) or
internal pressure (usually form subcutaneous infused fluid),
exceeds capillary perfusion pressure resulting in decreased blood
flow to the extremity. (A) should not be pursued until physical
causes of the pain are ruled out. (C) is less of a priority than
determining the effects of the edema on circulation and nerve
function. Further assessment of the client's ecchymosis can be
delayed until the signs of edema and compression that suggest
compartment syndrome have been examined (D).)
,The nurse assigns a UAP to obtain vital signs from a very anxious
client. What instructions should the nurse give the UAP?
A. Remain calm with the client and record abnormal results in the
chart.
B. Notify the medication nurse immediately if the pulse or blood
pressure is low.
C. Report the results of the vital signs to the nurse.
D. Reassure the client that the vital signs are normal. Correct
Answer C. Report the results of the vital signs to the nurse.
(Interpretation of the vital signs is the responsibility of the nurse,
so the UAP should report vital sign measurements of to the nurse
(C). (A, B, and D) require the UAP to interpret the vital signs,
which is beyond the scope of the UAP's authority.)
Twenty minutes after beginning a heat application, the client
states that the heating pad no longer feels warm enough. What is
the best response by the nurse?
A. That means you have derived the maximum benefit, and the
heat can be removed.
B. Your blood vessels are becoming dilated and removing the
heat from the site.
C. We will increase the temperature 5 degrees when the pad no
longer feels warm.
D. The body's receptors adapt over time as they are exposed to
heat. Correct Answer D. "The body's receptors adapt over time as
they are exposed to heat."
( (D) describes thermal adaptation, which occurs 20 to 30 minutes
after heat application. (A and B) provide false information. (C) is
not based on knowledge of physiology and is unsafe action that
may harm the client.)
When assessing a client with wrist restraints, the nurse observes
that the fingers on the right hand are blue. What action should the
nurse implement first?
A. Loosen the right wrist restraint.
,B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse. Correct Answer A. Loosen the
right wrist restraint.
(The priority nursing action is to restore circulation by loosening
the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry
(B) measures saturation of hemoglobin with oxygen and is not
indicated in situations where the cyanosis is related to mechanical
compression-- the restraints.)
An elderly client who requires frequent monitoring fell and
fractured a hip. Which nurse is at greatest risk for a malpractice
judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote
poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at
the time of the fall.
C. The nurse who transferred the client to the chair when the fall
occurred.
D. The charge nurse who completed rounds 30 minutes before
the fall occurred. Correct Answer C. The nurse who transferred
the client to the chair when the fall occurred.
(The four elements of malpractice are: breach of duty owed,
failure to adhere to the recognized standard of care, direct
causation of injury, and evidence of actual injury. The hip fracture
is the actual injury and the standard of care was "frequent
monitoring." (C) implies the duty was owed and the injury
occurred while the nurse was in charge of the client's care. There
is no evidence of negligence in (A, B, and D). )
The nurse observes an unlicensed assistive personnel (UAP)
taking a client's blood pressure with a cuff that is too small, but
, the blood pressure reading obtained is within the client's usual
range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled
assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood
pressure. Correct Answer B. Reassess the client's blood pressure
using a larger cuff.
(The most important action is to ensure that an accurate BP
reading is obtained. The nurse should reassess the BP with the
correct size cuff (B). Reassessment should not be postponed (A).
Though (C and D) are likely indicated, these actions do not have
the priority of (B).)
An elderly client with a fractured left hip is on strict bedrest. Which
nursing measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.
Correct Answer D. Gently life the client when moving into a
desired position.
(To avoid shearing forces when repositioning, the client should be
lifted gently across a surface (D). Reddened areas should NOT
be massaged (A) since this may increase the damage to already
traumatized skin. To control pain and muscle spasms, active
range of motion (B) may be limited on the affected leg. The
position described in (C) is contraindicated for a client with a
fractured left hip.)
The UAPs working on a chronic neuro unit ask the nurse to help
them determine the safest way to transfer an elderly client w/ left-
sided weakness from the bed to the chair. What method
describes the correct transfer procedure for this client?
