HESI FUNDAMENTALS EXAM QUESTIONS
AND CORRECT ANSWERS LATEST
UPDATED
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. - 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).
Correct Answer: B
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." - (D) describes
thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B)
provide false information. (C) is not based on a knowledge of physiology and is an
unsafe action that may harm the client.
Correct Answer: D
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
,A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
- Venous return is usually better in the upper extremities. Cannulation of the veins in
the lower extremities increases the risk of thrombus formation (B) which, if dislodged,
could be life-threatening. Superficial veins are often very easy (A) to find in the feet
and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than
handling an arm or hand. Even if the nurse did believe moving a cannulated leg was
more difficult, this is not the most important reason for using the upper extremities.
Pain (D) is not a consideration.
Correct Answer: B
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase." - Limiting saturated fat
from animal food sources to no more than 4 ounces per week (C) is an important diet
modification for lowering cholesterol. To be effective in reducing cholesterol, the
client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red
meat and all proteins do not need to be eliminated (B) to lower cholesterol, but
should be restricted to lean cuts of red meat and smaller portions (2-ounce servings).
The low density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine the
safest way to transfer an elderly client with left-sided weakness from the bed to the
chair. What method describes the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before moving.
B. Assist the client to a standing position, then place the right hand on the armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the right
foot. - (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of
transfer and include the use of poor body mechanics by the caregiver.
,Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - The
left sided Sims' position allows the enema solution to follow the anatomical course of
the intestines and allows the best overall results, so the UAP should reposition the
client in the Sims' position, which distributes the client's weight to the anterior ilium
(C). (A) is inaccurate. (B and D) should be implemented once the client is positioned.
Correct Answer: C
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern
should the nurse have for planning care in terms of the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. - Blood transfusions are forbidden (B) in the
Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C)
and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing
care is (B).
Correct Answer: B
The nurse observes that a male client has removed the covering from an ice pack
applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. - The first action taken by the
nurse should be to assess the skin for any possible thermal injury (A). If no injury to
the skin has occurred, the nurse can take the other actions (B, C, and D) as needed.
Correct Answer: A
, The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution
at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60
gtt/ml, how many drops per minute should the client receive?
A. 31 gtt/min.
B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. - (D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg.
Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine
how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client
is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive
2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D)
OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000
mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.
Correct Answer: D
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. - 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.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the
nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - The NGT should be flushed before,
after and in between each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and D) may be
implemented only after the tubing has been flushed.
AND CORRECT ANSWERS LATEST
UPDATED
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. - 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).
Correct Answer: B
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." - (D) describes
thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B)
provide false information. (C) is not based on a knowledge of physiology and is an
unsafe action that may harm the client.
Correct Answer: D
What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
,A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure.
- Venous return is usually better in the upper extremities. Cannulation of the veins in
the lower extremities increases the risk of thrombus formation (B) which, if dislodged,
could be life-threatening. Superficial veins are often very easy (A) to find in the feet
and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than
handling an arm or hand. Even if the nurse did believe moving a cannulated leg was
more difficult, this is not the most important reason for using the upper extremities.
Pain (D) is not a consideration.
Correct Answer: B
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase." - Limiting saturated fat
from animal food sources to no more than 4 ounces per week (C) is an important diet
modification for lowering cholesterol. To be effective in reducing cholesterol, the
client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red
meat and all proteins do not need to be eliminated (B) to lower cholesterol, but
should be restricted to lean cuts of red meat and smaller portions (2-ounce servings).
The low density lipoproteins (D) need to decrease rather than increase.
Correct Answer: C
The UAPs working on a chronic neuro unit ask the nurse to help them determine the
safest way to transfer an elderly client with left-sided weakness from the bed to the
chair. What method describes the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side before moving.
B. Assist the client to a standing position, then place the right hand on the armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the client on the right
foot. - (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of
transfer and include the use of poor body mechanics by the caregiver.
,Correct Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition in a Sim's position with the client's weight on the anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level. - The
left sided Sims' position allows the enema solution to follow the anatomical course of
the intestines and allows the best overall results, so the UAP should reposition the
client in the Sims' position, which distributes the client's weight to the anterior ilium
(C). (A) is inaccurate. (B and D) should be implemented once the client is positioned.
Correct Answer: C
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern
should the nurse have for planning care in terms of the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed. - Blood transfusions are forbidden (B) in the
Jehovah's Witness religion. Judaism prohibits (A). Buddhism forbids the use of (C)
and drugs. Many of these sects are vegetarian (D), but the direct impact on nursing
care is (B).
Correct Answer: B
The nurse observes that a male client has removed the covering from an ice pack
applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. - The first action taken by the
nurse should be to assess the skin for any possible thermal injury (A). If no injury to
the skin has occurred, the nurse can take the other actions (B, C, and D) as needed.
Correct Answer: A
, The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution
at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60
gtt/ml, how many drops per minute should the client receive?
A. 31 gtt/min.
B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. - (D) is the correct calculation: Convert lbs to kg: 182/2.2 = 82.73 kg.
Determine the dosage for this client: 5 mcg × 82.73 = 413.65 mcg/min. Determine
how many mcg are contained in 1 ml: 250/50,000 mcg = 200 mcg per ml. The client
is to receive 413.65 mcg/min, and there are 200 mcg/ml; so the client is to receive
2.07ml per minute. With a drip factor of 60 gtt/ml, then 60 × 2.07 = 124.28 gtt/min (D)
OR, using dimensional analysis: gtt/min = 60 gtt/ml X 250 ml/50 mg X 1 mg/1,000
mcg X 5 mcg/kg/min X 1 kg/2.2 lbs X 182 lbs.
Correct Answer: D
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. - 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.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the
nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - The NGT should be flushed before,
after and in between each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and D) may be
implemented only after the tubing has been flushed.
