HESI Fundamentals of nursing Actual Exam (A
Grade) Exam |Questions AND 100% CORRECT
ANSWERS
A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a
scheduled chemotherapy treatment, and states that she is ready to go home to die. What
intervention should the nurse initiate?
A) Review the client's medical record for an advance directive.
B) Determine if a do-not-resuscitate prescription has been obtained.
C) Document that the client is being discharged against medical advice.
D) Evaluate the client's mental status for competence to refuse treatment. - ✔✔Answer: D
Rationale
Competent clients have the right to refuse treatment, so the nurse should first ensure that the
client is competent (D). (A and C) are not necessary for a competent client to refuse treatment.
The nurse cannot document (C) until the healthcare provider is notified of the client's wishes
and a discharge prescription is obtained.
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to
impending death." What intervention is best for the nurse to implement when caring for this
client?
A) Help the client to accept the final stage of life.
B) Assist and support the client in establishing short-term goals.
C) Encourage the client to make future plans, even if they are unrealistic.
D) Instruct the client's family to focus on positive aspects of the client's life. - ✔✔Answer: B
Rationale
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse
should help the client set short-term goals, and recognize the achievement of immediate goals
,(B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful
intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be
implemented, but does not have the priority of (B).
A male client with venous incompetence stands up and his blood pressure subsequently drops.
Which finding should the nurse identify as a compensatory response?
A) Bradycardia.
B) Increase in pulse rate.
C) Peripheral vasodilation.
D) Increase in cardiac output. - ✔✔Answer: B
Rationale
When postural hypotension occurs, the body attempts to restore arterial pressure by
stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral
vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence
through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs
when orthostatic hypotension occurs.
In evaluating client care, which action should the nurse take first?
A) Determine if the expected outcomes of care were achieved.
B) Review the rationales used as the basis of nursing actions.
C) Document the care plan goals that were successfully met.
D) Prioritize interventions to be added to the client's plan of care. - ✔✔Answer: A
Rationale
In evaluating care, the nurse should first determine if the expected outcomes of the plan of
care were achieved.
When caring for an immobile client, what nursing diagnosis has the highest priority?
,A) Risk for fluid volume deficit.
B) Impaired gas exchange.
C) Risk for impaired skin integrity.
D) Altered tissue perfusion. - ✔✔Answer: B
Rationale
The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange (B)
implies that the client is having trouble with breathing, which has the highest priority of the
nursing diagnoses listed. Though an immobilized client presents a multitude of nursing care
challenges, (A, C, and D) do not have the priority of (B).
What action is most important for the nurse to implement when placing a client in the Sim's
position?
A) Raise the bed to a waist-high working level.
B) Elevate the head of the bed 45 degrees.
C) Place a pillow behind the client's back.
D) Bring the client to one edge of the bed. - ✔✔Answer: A
Rationale
A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's
proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying
position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the
client closer to the nurse when being turned.
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. - ✔✔Answer: B
, Rationale
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the
irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid
instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied
(A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can
be subtracted from the output at that time.
While the nurse is administering a bolus feeding to a client via nasogastric tube, the client
begins to vomit. What action should the nurse implement first?
A) Discontinue the administration of the bolus feeding.
B) Auscultate the client's breath sounds bilaterally.
C) Elevate the head of the bed to a high Fowler's position.
D) Administer a PRN dose of a prescribed antiemetic. - ✔✔Answer: A
Rationale
When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding
(A) to prevent further vomiting. (C) should then be implemented to reduce the risk of
aspiration. After that, (B and D) can be implemented as indicated.
Which technique is most important for the nurse to implement when performing a physical
assessment?
A) A head-to-toe approach.
B) The medical systems model.
C) A consistent, systematic approach.
D) An approach related to a nursing model. - ✔✔Answer: C
Rationale
The most important factor in performing a physical assessment is following a consistent and
systematic technique (C) each time an assessment is performed to minimize variation in
sequence which may increase the likelihood of omitting a step or exam of an isolated area. The
Grade) Exam |Questions AND 100% CORRECT
ANSWERS
A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a
scheduled chemotherapy treatment, and states that she is ready to go home to die. What
intervention should the nurse initiate?
A) Review the client's medical record for an advance directive.
B) Determine if a do-not-resuscitate prescription has been obtained.
C) Document that the client is being discharged against medical advice.
D) Evaluate the client's mental status for competence to refuse treatment. - ✔✔Answer: D
Rationale
Competent clients have the right to refuse treatment, so the nurse should first ensure that the
client is competent (D). (A and C) are not necessary for a competent client to refuse treatment.
The nurse cannot document (C) until the healthcare provider is notified of the client's wishes
and a discharge prescription is obtained.
A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to
impending death." What intervention is best for the nurse to implement when caring for this
client?
A) Help the client to accept the final stage of life.
B) Assist and support the client in establishing short-term goals.
C) Encourage the client to make future plans, even if they are unrealistic.
D) Instruct the client's family to focus on positive aspects of the client's life. - ✔✔Answer: B
Rationale
Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse
should help the client set short-term goals, and recognize the achievement of immediate goals
,(B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful
intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be
implemented, but does not have the priority of (B).
A male client with venous incompetence stands up and his blood pressure subsequently drops.
Which finding should the nurse identify as a compensatory response?
A) Bradycardia.
B) Increase in pulse rate.
C) Peripheral vasodilation.
D) Increase in cardiac output. - ✔✔Answer: B
Rationale
When postural hypotension occurs, the body attempts to restore arterial pressure by
stimulating the baro-receptors to increase the heart rate (B), not decrease it (A). Peripheral
vasoconstriction, not dilation (C), of the veins and arterioles occurs with venous incompetence
through the baro-receptor reflex. A decrease in cardiac output, not an increase (D), occurs
when orthostatic hypotension occurs.
In evaluating client care, which action should the nurse take first?
A) Determine if the expected outcomes of care were achieved.
B) Review the rationales used as the basis of nursing actions.
C) Document the care plan goals that were successfully met.
D) Prioritize interventions to be added to the client's plan of care. - ✔✔Answer: A
Rationale
In evaluating care, the nurse should first determine if the expected outcomes of the plan of
care were achieved.
When caring for an immobile client, what nursing diagnosis has the highest priority?
,A) Risk for fluid volume deficit.
B) Impaired gas exchange.
C) Risk for impaired skin integrity.
D) Altered tissue perfusion. - ✔✔Answer: B
Rationale
The ABCs of caring for clients are airway, breathing, and circulation. Impaired gas exchange (B)
implies that the client is having trouble with breathing, which has the highest priority of the
nursing diagnoses listed. Though an immobilized client presents a multitude of nursing care
challenges, (A, C, and D) do not have the priority of (B).
What action is most important for the nurse to implement when placing a client in the Sim's
position?
A) Raise the bed to a waist-high working level.
B) Elevate the head of the bed 45 degrees.
C) Place a pillow behind the client's back.
D) Bring the client to one edge of the bed. - ✔✔Answer: A
Rationale
A waist-high bed height (A) is a comfortable and safe working height to maintain the nurse's
proper body mechanics and prevent back injury. The head should be flat for a Sim's side-lying
position, not raised (B). (C) is implemented after the client is positioned laterally. (D) brings the
client closer to the nurse when being turned.
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. - ✔✔Answer: B
, Rationale
To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the
irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid
instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's
catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied
(A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can
be subtracted from the output at that time.
While the nurse is administering a bolus feeding to a client via nasogastric tube, the client
begins to vomit. What action should the nurse implement first?
A) Discontinue the administration of the bolus feeding.
B) Auscultate the client's breath sounds bilaterally.
C) Elevate the head of the bed to a high Fowler's position.
D) Administer a PRN dose of a prescribed antiemetic. - ✔✔Answer: A
Rationale
When a client receiving a tube feeding begins to vomit, the nurse should first stop the feeding
(A) to prevent further vomiting. (C) should then be implemented to reduce the risk of
aspiration. After that, (B and D) can be implemented as indicated.
Which technique is most important for the nurse to implement when performing a physical
assessment?
A) A head-to-toe approach.
B) The medical systems model.
C) A consistent, systematic approach.
D) An approach related to a nursing model. - ✔✔Answer: C
Rationale
The most important factor in performing a physical assessment is following a consistent and
systematic technique (C) each time an assessment is performed to minimize variation in
sequence which may increase the likelihood of omitting a step or exam of an isolated area. The
