Hesi Funds w/ rationale with correct
answers 100% 2026
Before administering a client's medication, the nurse assesses a change in the pts condition and
decides to withhold the medication until consulting with the HCP. After consultation with the
HCP, the dose of the medication is changed and the nurse administers the newly prescribed
dose an hour later than the originally scheduled time. What action should the nurse implement
in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record. - Correct Answers C
The nurse should correct the action and document the events that occurred in the nurses notes
(C). (A) did not occur and (B) is not indicated. Med admin record is part of the pts medical
record and should be placed in the chart. (D) when no longer current.
The nurse encounters resistance when inserting the tubing into a pts rectum for a tap water
enema. What action should the nurse implement?
A. Withdraw the tube and apply additional lubricant to the tube.
B. Encourage the pt to bear down and continue to insert the tube.
C. Remove the tube and check the client for a fecal impaction.
D. Ask the client to relax and run a small amount of fluid into the rectum. - Correct Answers D
If resistance is encountered during the initial insertion of an enema tube, the pt should be
instructed to relax while a small amount of solution runs through the tube into the rectum (D)
to promote dilation. (A) is unlikely to resolve the problem, (B) may cause injury, (C) should not
be implemented until other, less invasive actions are taken.
, While the nurse is administering a bolus feeding to a client via nasogastric tube, the pt begins to
vomit. What action should the nurse implement first?
A. Discontinue the admin of the bolus feeding.
B. Auscultate the pts breath sounds bilaterally.
C. Elevate the HOB to a high fowlers position.
D. Admin a PRN does of a prescribed antiemetic. - Correct Answers A
During tube feeding if a ot vomits, the nurse should stop the feeding (A) to prevent further
vomiting. (C) should then be implemented to reduce the risk o aspiration. After that (B, D) can
be implemented as indicated.
The nurse is prepping a male pt 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 actions(s) should
the RN implement before assisting the client to the chair? (select all that apply)
A. Pre medicate the pt with an analgesic.
B. Inform the pt of the plan for moving to the chair.
C. Obtain and place a portable commode by the bed.
D. Ask the pt to push the IV pole to the chair.
E. Clamp the indwelling cath
F. Assess the pts blood pressure - Correct Answers A, B, D, F
Analgesic pre-meds (A) reduces pts pain during mobilization and maximize compliance. To
ensure cooperation and promote independence, the nurse should inform the pt about the plan
(B) and encourage the pt to participate by pushing the IV pole (D). Assess BP (F) proir to
mobilization which can cause orthostatic hypotension. (C, E) are not indicated.
answers 100% 2026
Before administering a client's medication, the nurse assesses a change in the pts condition and
decides to withhold the medication until consulting with the HCP. After consultation with the
HCP, the dose of the medication is changed and the nurse administers the newly prescribed
dose an hour later than the originally scheduled time. What action should the nurse implement
in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record. - Correct Answers C
The nurse should correct the action and document the events that occurred in the nurses notes
(C). (A) did not occur and (B) is not indicated. Med admin record is part of the pts medical
record and should be placed in the chart. (D) when no longer current.
The nurse encounters resistance when inserting the tubing into a pts rectum for a tap water
enema. What action should the nurse implement?
A. Withdraw the tube and apply additional lubricant to the tube.
B. Encourage the pt to bear down and continue to insert the tube.
C. Remove the tube and check the client for a fecal impaction.
D. Ask the client to relax and run a small amount of fluid into the rectum. - Correct Answers D
If resistance is encountered during the initial insertion of an enema tube, the pt should be
instructed to relax while a small amount of solution runs through the tube into the rectum (D)
to promote dilation. (A) is unlikely to resolve the problem, (B) may cause injury, (C) should not
be implemented until other, less invasive actions are taken.
, While the nurse is administering a bolus feeding to a client via nasogastric tube, the pt begins to
vomit. What action should the nurse implement first?
A. Discontinue the admin of the bolus feeding.
B. Auscultate the pts breath sounds bilaterally.
C. Elevate the HOB to a high fowlers position.
D. Admin a PRN does of a prescribed antiemetic. - Correct Answers A
During tube feeding if a ot vomits, the nurse should stop the feeding (A) to prevent further
vomiting. (C) should then be implemented to reduce the risk o aspiration. After that (B, D) can
be implemented as indicated.
The nurse is prepping a male pt 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 actions(s) should
the RN implement before assisting the client to the chair? (select all that apply)
A. Pre medicate the pt with an analgesic.
B. Inform the pt of the plan for moving to the chair.
C. Obtain and place a portable commode by the bed.
D. Ask the pt to push the IV pole to the chair.
E. Clamp the indwelling cath
F. Assess the pts blood pressure - Correct Answers A, B, D, F
Analgesic pre-meds (A) reduces pts pain during mobilization and maximize compliance. To
ensure cooperation and promote independence, the nurse should inform the pt about the plan
(B) and encourage the pt to participate by pushing the IV pole (D). Assess BP (F) proir to
mobilization which can cause orthostatic hypotension. (C, E) are not indicated.
