HESI FUNDAMENTALS FINAL EXAM ACTUAL QUESTIONS
AND ANSWERS GRADED A+
✔✔Examination of a client complaining of itching on his right arm reveals a rash made
up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How
should the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ✔✔B.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. (Macules are
localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance (B) rather than simply naming
the condition. (A) identifies vesicles-- fluid filled blisters--an incorrect description given
the symptoms listed. (C) identifies papule-- solid elevated lesions, again not correctly
identifying the symptoms. (D) identifies petechiae-- pinpoint red to purple skin
discolorations that do not itch, again an incorrect identification.)
✔✔At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. What would be an appropriate response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery,
the better you will feel."
B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her
experiences with you." - ✔✔C. "It is OK if you don't want to talk about your surgery. I will
be available when you are ready."
( (C) displays sensitivity and understanding without judging the client. (A) is judgmental
in that it is telling the client how she feels and is also insensitive. (B) would give the
client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support if not offered, this response could be
interpreted as dismissing the client and avoiding the problem.)
✔✔The nurse is evaluating a client learning about a low-sodium diet. Selection of which
meal would indicate to the nurse that this client understands the dietary restrictions? -
✔✔Skim milk, turkey salad, roll, and vanilla ice cream
✔✔The nurse prepares a 1000 mL IV of 5% dextrose and water to be infused over 8
hours. The infusion set delivers 10 drops per milliliter . The nurse should regulate the IV
to administer approximately how many drops per minute? - ✔✔21
,✔✔An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the best
client position for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sim's
D. Supine - ✔✔B. Fowler's
(The client should be positioned in a semi-setting (B) position during feeding to
decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to
placement by a percutaneous endoscopic gastronomy procedure, is inserted directly
into the stomach through an incision in the abdomen for long-term administration of
nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on
the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk
for aspiration.)
✔✔Which action is the most important to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. - ✔✔C. Keep gloved hands above the
elbows. (Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the glove on the
dominant hand first, it is not necessary to ensure asepsis (D).)
✔✔The nurse is teaching a client with numerous allergies how to avoid allergens. Which
instruction should be included in this teaching plan?
A. Avoid any types of sprays, powders, and perfumes.
B. Wearing a mask while cleaning will not help to avoid allergens.
C. Purchase any type of clothing, but be sure it is washed before wearing it.
D. Pollen count is related to hay fever, not to allergens. - ✔✔A. Avoid any type of
sprays, powders, and perfumes.
✔✔A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a
fracture resulting from a fall. In reviewing hip precautions with the client, which
instruction should the nurse include in this client's teaching plan?
A. "In 8 weeks you will be able to bend at the waist to reach items on the floor."
B. "Place a pillow between your knees while lying in bed to prevent hip dislocation."
C. "It is safe to use a walker to get out of bed, but you need assistance when walking."
D. "Take pain medication 30 minutes after your physical therapy sessions." - ✔✔B.
"Place a pillow between your knees while lying in bed to prevent hip dislocation."
(The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at
risk of dislocation for 6 months to a year following the procedure. Hip precautions to
prevent dislocation include placing a pillow between the knees to maintain abduction of
the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek
assistance for both standing and walking until they are stable on a walker or cane (C),
, and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather
than waiting until the pain level is high after their therapy.)
✔✔The nurse is performing nasotracheal suctioning. After suctioning the client's trachea
for fifteen seconds, large amounts of thick yellow secretions return. What action should
the nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. - ✔✔D. Re-oxygenate
the client before attempting to suction again.
✔✔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. - ✔✔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. - ✔✔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.
AND ANSWERS GRADED A+
✔✔Examination of a client complaining of itching on his right arm reveals a rash made
up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How
should the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ✔✔B.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. (Macules are
localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance (B) rather than simply naming
the condition. (A) identifies vesicles-- fluid filled blisters--an incorrect description given
the symptoms listed. (C) identifies papule-- solid elevated lesions, again not correctly
identifying the symptoms. (D) identifies petechiae-- pinpoint red to purple skin
discolorations that do not itch, again an incorrect identification.)
✔✔At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. What would be an appropriate response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery,
the better you will feel."
B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her
experiences with you." - ✔✔C. "It is OK if you don't want to talk about your surgery. I will
be available when you are ready."
( (C) displays sensitivity and understanding without judging the client. (A) is judgmental
in that it is telling the client how she feels and is also insensitive. (B) would give the
client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support if not offered, this response could be
interpreted as dismissing the client and avoiding the problem.)
✔✔The nurse is evaluating a client learning about a low-sodium diet. Selection of which
meal would indicate to the nurse that this client understands the dietary restrictions? -
✔✔Skim milk, turkey salad, roll, and vanilla ice cream
✔✔The nurse prepares a 1000 mL IV of 5% dextrose and water to be infused over 8
hours. The infusion set delivers 10 drops per milliliter . The nurse should regulate the IV
to administer approximately how many drops per minute? - ✔✔21
,✔✔An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the best
client position for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sim's
D. Supine - ✔✔B. Fowler's
(The client should be positioned in a semi-setting (B) position during feeding to
decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to
placement by a percutaneous endoscopic gastronomy procedure, is inserted directly
into the stomach through an incision in the abdomen for long-term administration of
nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on
the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk
for aspiration.)
✔✔Which action is the most important to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. - ✔✔C. Keep gloved hands above the
elbows. (Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the glove on the
dominant hand first, it is not necessary to ensure asepsis (D).)
✔✔The nurse is teaching a client with numerous allergies how to avoid allergens. Which
instruction should be included in this teaching plan?
A. Avoid any types of sprays, powders, and perfumes.
B. Wearing a mask while cleaning will not help to avoid allergens.
C. Purchase any type of clothing, but be sure it is washed before wearing it.
D. Pollen count is related to hay fever, not to allergens. - ✔✔A. Avoid any type of
sprays, powders, and perfumes.
✔✔A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a
fracture resulting from a fall. In reviewing hip precautions with the client, which
instruction should the nurse include in this client's teaching plan?
A. "In 8 weeks you will be able to bend at the waist to reach items on the floor."
B. "Place a pillow between your knees while lying in bed to prevent hip dislocation."
C. "It is safe to use a walker to get out of bed, but you need assistance when walking."
D. "Take pain medication 30 minutes after your physical therapy sessions." - ✔✔B.
"Place a pillow between your knees while lying in bed to prevent hip dislocation."
(The client's affected hip joint following a hemiarthroplasty (partial hip replacement) is at
risk of dislocation for 6 months to a year following the procedure. Hip precautions to
prevent dislocation include placing a pillow between the knees to maintain abduction of
the hips (B). Clients should be instructed to avoid bending at the waist (A), to seek
assistance for both standing and walking until they are stable on a walker or cane (C),
, and to take pain medication 20 to 30 minutes prior to physical therapy sessions, rather
than waiting until the pain level is high after their therapy.)
✔✔The nurse is performing nasotracheal suctioning. After suctioning the client's trachea
for fifteen seconds, large amounts of thick yellow secretions return. What action should
the nurse implement next?
A. Encourage the client to cough to help loosen secretions.
B. Advise the client to increase the intake of oral fluids.
C. Rotate the suction catheter to obtain any remaining secretions.
D. Re-oxygenate the client before attempting to suction again. - ✔✔D. Re-oxygenate
the client before attempting to suction again.
✔✔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. - ✔✔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. - ✔✔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.
