- HESI RN FUNDAMENTALS
,SAMPLE QUESTIONS/PREVIEW
1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of
pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious.
What action is most important for the nurse to implement? Provide written instructions that are easy
to follow.
2. Which assessment finding is most significant in determining the level of assistance a client needs
with personal care? Disorientation to time, place, and person
3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and
palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client
to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the
urinary catheter.
4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about
his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client
what is making him grimace.
5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the
nurse obtain first? Respiratory rate
,6. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid
medications through a gastrostomy tube used for continuous feeding, as seen in the video. What
actions should the nurse take? (SATA)
Confirm that the nurse determined the amount of gastric
residualAdd the liquid volumes when documenting fluid
intake
Instruct the nurse to administer each mediation separately
7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe
nurse take nest? Apply intermittent suction
8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours
after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a
call to the healthcare provider, what action should the nurse implement? Instruct the client to use
guided imagery and slow rhythmic breathing.
9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has
viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the
UAP? Wear gloves while giving a bath
10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action
indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s
room.
11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which
client should be assessed regularly during the night for sleep apnea? An older male with multiple
problems, including obesity, diabetes, and hypertension.
12. It is most important for the nurse to recalculate the Braden scale for a client who has developed
which problem? Urinary incontinence
, 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the
client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe
top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching
the client how to walk with the crutches.
14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary
pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse
respond? Encourage discussion about the concern and fears.
15. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform
which client assessment? Vital signs
16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby?
What did I do wrong?” Which response is most helpful? “This must be a very difficult
time for you.”
17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling
urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the
normal saline 20 ml
18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a
radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit
reading
19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action
should the nurse take? Stay with the client in silence while touching her forearm
20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was
accidentally flushed instead of saving in the container. What intervention should the nurse initiate?
Discard the urine and start another 24-hour period
21. A confused elderly male client is having trouble sleeping at night and is sometimes found
wandering the hallway. What nursing intervention should the nurse implement first? Provide a
back rub at bedtime
22. A young male client with testicular cancer has a living will that describes his desire that no
extraordinary measures be taken to save his life. The healthcare provider knows the client has agood
prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the
nurse take? Initiate an ethics committee review of the case
23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto
respond to most commands. Before starting to feed the client, which information is most important
for the nurse to obtain? Client's ability to chew and swallow
24. The nurse enters the room of a client with a Clostridium difficile infection to administer an
intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning
the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is
wearing gloves but not a gown. What action should the nurse implement first? Tell UAP
put a gown on
25. The computer documentation system shuts down while the nurse is entering the client’s physical
assessment data. What should the nurse do first? Wait for notification services department of the
situation
26. In assessing a client who has a nursing diagnosis of spiritual distress, which action should thenurse
take first? Assist and support the client in establishing short-term goals.
,SAMPLE QUESTIONS/PREVIEW
1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of
pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious.
What action is most important for the nurse to implement? Provide written instructions that are easy
to follow.
2. Which assessment finding is most significant in determining the level of assistance a client needs
with personal care? Disorientation to time, place, and person
3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and
palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client
to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the
urinary catheter.
4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about
his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client
what is making him grimace.
5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the
nurse obtain first? Respiratory rate
,6. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid
medications through a gastrostomy tube used for continuous feeding, as seen in the video. What
actions should the nurse take? (SATA)
Confirm that the nurse determined the amount of gastric
residualAdd the liquid volumes when documenting fluid
intake
Instruct the nurse to administer each mediation separately
7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe
nurse take nest? Apply intermittent suction
8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours
after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a
call to the healthcare provider, what action should the nurse implement? Instruct the client to use
guided imagery and slow rhythmic breathing.
9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has
viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the
UAP? Wear gloves while giving a bath
10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action
indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s
room.
11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which
client should be assessed regularly during the night for sleep apnea? An older male with multiple
problems, including obesity, diabetes, and hypertension.
12. It is most important for the nurse to recalculate the Braden scale for a client who has developed
which problem? Urinary incontinence
, 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the
client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe
top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching
the client how to walk with the crutches.
14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary
pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse
respond? Encourage discussion about the concern and fears.
15. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform
which client assessment? Vital signs
16. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby?
What did I do wrong?” Which response is most helpful? “This must be a very difficult
time for you.”
17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling
urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the
normal saline 20 ml
18. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a
radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit
reading
19. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action
should the nurse take? Stay with the client in silence while touching her forearm
20. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was
accidentally flushed instead of saving in the container. What intervention should the nurse initiate?
Discard the urine and start another 24-hour period
21. A confused elderly male client is having trouble sleeping at night and is sometimes found
wandering the hallway. What nursing intervention should the nurse implement first? Provide a
back rub at bedtime
22. A young male client with testicular cancer has a living will that describes his desire that no
extraordinary measures be taken to save his life. The healthcare provider knows the client has agood
prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the
nurse take? Initiate an ethics committee review of the case
23. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto
respond to most commands. Before starting to feed the client, which information is most important
for the nurse to obtain? Client's ability to chew and swallow
24. The nurse enters the room of a client with a Clostridium difficile infection to administer an
intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning
the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is
wearing gloves but not a gown. What action should the nurse implement first? Tell UAP
put a gown on
25. The computer documentation system shuts down while the nurse is entering the client’s physical
assessment data. What should the nurse do first? Wait for notification services department of the
situation
26. In assessing a client who has a nursing diagnosis of spiritual distress, which action should thenurse
take first? Assist and support the client in establishing short-term goals.
