FUNDAMENTAL HESI UPDATED 2026 EXAMINERS
QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is obtaining a health history from the newly admitted client who has chronic
pain in the knee. What should the nurse include in the pain assessment? Select all that
apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation - ✔✔1,3
Accurate pain assessment includes pain history with the client's identification of pain
location, intensity, and quality and helps the nurse to identify what pain means to the
client. The pattern of pain includes time of onset, duration, and recurrence of pain and
its assessment helps the nurse anticipate and meet the needs of the client. Assessment
,of the precipitating factors helps the nurse prevent the pain and determine it cause.
Purposeless movements such as tossing and turning or involuntary movements such as
a reflexive jerking may indicate pain. Physiological responses such as elevated blood
pressure and heart rate are most likely to be absent in the client with chronic pain. Pain
is a subjective experience and therefore the nurse has to ask the client directly instead
of accepting statement of the family members.
✔✔While undergoing a soapsuds enema, the client reports abdominal cramping. What
action should the nurse take?
1
Immediately stop the infusion.
2
Lower the height of the enema bag.
3
Advance the enema tubing 2 to 3 inches.
4
Clamp the tube for 2 minutes, then restart the infusion. - ✔✔2
Abdominal cramping during a soapsuds enema may be due to too rapid administration
of the enema solution. Lowering the height of the enema bag slows the flow and allows
the bowel time to adapt to the distention without causing excessive discomfort. Stopping
the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping
the tube for several minutes then restarting the infusion may be attempted if slowing the
infusion does not relieve the cramps.
✔✔During the initial physical assessment of a newly admitted client with a pressure
ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies
emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's
actions adequate?
1
The nurse also should have instituted a plan to increase activity.
2
The nurse provided supportive nursing care for the well-being of the client.
3
Debridement of the pressure ulcer should have been done before the dressing was
applied.
4
Treatment should not have been instituted until the health care provider's prescriptions
were received. - ✔✔2
According to the Nurse Practice Act, a nurse may independently treat human responses
to actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing
was applied. Application of an emollient and reinforcing a dressing are independent
nursing functions.
,✔✔A visitor comes to the nursing station and tells the nurse that a client and his relative
had a fight and that the client is now lying unconscious on the floor. What is the most
important action the nurse needs to take?
1
Ask the client if he is okay.
2
Call security from the room.
3
Find out if there is anyone else in the room.
4
Ask security to make sure the room is safe - ✔✔4
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if
the client is okay and make sure that any other people in the room are safe
✔✔To ensure the safety of a client who is receiving a continuous intravenous normal
saline infusion, the nurse should change the administration set every:
1
4 to 8 hours
2
12 to 24 hours
3
24 to 48 hours
4
72 to 96 hours - ✔✔4
Best practice guidelines recommend replacing administration sets no more frequently
than 72 to 96 hours after initiation of use in patients not receiving blood, blood products,
or fat emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
✔✔A nurse is taking care of a client who has severe back pain as a result of a work
injury. What nursing considerations should be made when determining the client's plan
of care? Select all that apply.
1
Ask the client what is the client's acceptable level of pain.
2
Eliminate all activities that precipitate the pain.
3
Administer the pain medications regularly around the clock.
4
Use a different pain scale each time to promote patient education.
5
Assess the client's pain every 15 minutes - ✔✔1,3
The nurse works together with the client in order to determine the tolerable level of pain.
Considering that the client has chronic, not acute pain, the goal of the pain management
is to decrease pain to the tolerable level instead of eliminating pain completely.
, Administration of pain medications around the clock will provide the stable level of pain
medication in the blood and relieve the pain. Elimination of all activities that precipitate
the client's pain is not possible even though the nurse will try to minimize such activities.
The same pain scale should be used for assessment of the client's pain level helps to
ensure consistency and accuracy in the pain assessment. Only management of acute
pain such as postoperative pain requires the pain assessment at frequent intervals.
✔✔The nurse is preparing to administer eardrops to a client that has impacted
cerumen. Before administering the drops, the nurse will assess the client for which
contraindications? Select all that apply.
1
Allergy to the medication
2
Itching in the ear canal
3
Drainage from the ear canal
4
Tympanic membrane rupture
5
Partial hearing loss in the affected ear - ✔✔1,3,4
Contraindications to eardrops include allergy to the medication, drainage from the ear
canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted
cerumen and is not a contraindication to the use of eardrops. Itching may occur with
some ear conditions and is not a contraindication to the use of eardrops.
✔✔What clinical indicators should the nurse expect a client with hyperkalemia to
exhibit? Select all that apply.
1
Tetany
2
Seizures
3
Diarrhea
4
Weakness
5
Dysrhythmias - ✔✔3,4,5
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are
associated with low calcium or sodium levels. Because of potassium's role in the
sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac
dysrhythmias.
✔✔A health care provider has prescribed isoniazid (Laniazid) for a client. Which
instruction should the nurse give the client about this medication?
1
Prolonged use can cause dark concentrated urine.
QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is obtaining a health history from the newly admitted client who has chronic
pain in the knee. What should the nurse include in the pain assessment? Select all that
apply.
1
Pain history, including location, intensity, and quality of pain
2
Client's purposeful body movement in arranging the papers on the bedside table
3
Pain pattern, including precipitating and alleviating factors
4
Vital signs such as increased blood pressure and heart rate
5
The client's family statement about increases in pain with ambulation - ✔✔1,3
Accurate pain assessment includes pain history with the client's identification of pain
location, intensity, and quality and helps the nurse to identify what pain means to the
client. The pattern of pain includes time of onset, duration, and recurrence of pain and
its assessment helps the nurse anticipate and meet the needs of the client. Assessment
,of the precipitating factors helps the nurse prevent the pain and determine it cause.
Purposeless movements such as tossing and turning or involuntary movements such as
a reflexive jerking may indicate pain. Physiological responses such as elevated blood
pressure and heart rate are most likely to be absent in the client with chronic pain. Pain
is a subjective experience and therefore the nurse has to ask the client directly instead
of accepting statement of the family members.
✔✔While undergoing a soapsuds enema, the client reports abdominal cramping. What
action should the nurse take?
1
Immediately stop the infusion.
2
Lower the height of the enema bag.
3
Advance the enema tubing 2 to 3 inches.
4
Clamp the tube for 2 minutes, then restart the infusion. - ✔✔2
Abdominal cramping during a soapsuds enema may be due to too rapid administration
of the enema solution. Lowering the height of the enema bag slows the flow and allows
the bowel time to adapt to the distention without causing excessive discomfort. Stopping
the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping
the tube for several minutes then restarting the infusion may be attempted if slowing the
infusion does not relieve the cramps.
✔✔During the initial physical assessment of a newly admitted client with a pressure
ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies
emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's
actions adequate?
1
The nurse also should have instituted a plan to increase activity.
2
The nurse provided supportive nursing care for the well-being of the client.
3
Debridement of the pressure ulcer should have been done before the dressing was
applied.
4
Treatment should not have been instituted until the health care provider's prescriptions
were received. - ✔✔2
According to the Nurse Practice Act, a nurse may independently treat human responses
to actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing
was applied. Application of an emollient and reinforcing a dressing are independent
nursing functions.
,✔✔A visitor comes to the nursing station and tells the nurse that a client and his relative
had a fight and that the client is now lying unconscious on the floor. What is the most
important action the nurse needs to take?
1
Ask the client if he is okay.
2
Call security from the room.
3
Find out if there is anyone else in the room.
4
Ask security to make sure the room is safe - ✔✔4
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if
the client is okay and make sure that any other people in the room are safe
✔✔To ensure the safety of a client who is receiving a continuous intravenous normal
saline infusion, the nurse should change the administration set every:
1
4 to 8 hours
2
12 to 24 hours
3
24 to 48 hours
4
72 to 96 hours - ✔✔4
Best practice guidelines recommend replacing administration sets no more frequently
than 72 to 96 hours after initiation of use in patients not receiving blood, blood products,
or fat emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
✔✔A nurse is taking care of a client who has severe back pain as a result of a work
injury. What nursing considerations should be made when determining the client's plan
of care? Select all that apply.
1
Ask the client what is the client's acceptable level of pain.
2
Eliminate all activities that precipitate the pain.
3
Administer the pain medications regularly around the clock.
4
Use a different pain scale each time to promote patient education.
5
Assess the client's pain every 15 minutes - ✔✔1,3
The nurse works together with the client in order to determine the tolerable level of pain.
Considering that the client has chronic, not acute pain, the goal of the pain management
is to decrease pain to the tolerable level instead of eliminating pain completely.
, Administration of pain medications around the clock will provide the stable level of pain
medication in the blood and relieve the pain. Elimination of all activities that precipitate
the client's pain is not possible even though the nurse will try to minimize such activities.
The same pain scale should be used for assessment of the client's pain level helps to
ensure consistency and accuracy in the pain assessment. Only management of acute
pain such as postoperative pain requires the pain assessment at frequent intervals.
✔✔The nurse is preparing to administer eardrops to a client that has impacted
cerumen. Before administering the drops, the nurse will assess the client for which
contraindications? Select all that apply.
1
Allergy to the medication
2
Itching in the ear canal
3
Drainage from the ear canal
4
Tympanic membrane rupture
5
Partial hearing loss in the affected ear - ✔✔1,3,4
Contraindications to eardrops include allergy to the medication, drainage from the ear
canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted
cerumen and is not a contraindication to the use of eardrops. Itching may occur with
some ear conditions and is not a contraindication to the use of eardrops.
✔✔What clinical indicators should the nurse expect a client with hyperkalemia to
exhibit? Select all that apply.
1
Tetany
2
Seizures
3
Diarrhea
4
Weakness
5
Dysrhythmias - ✔✔3,4,5
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are
associated with low calcium or sodium levels. Because of potassium's role in the
sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and cardiac
dysrhythmias.
✔✔A health care provider has prescribed isoniazid (Laniazid) for a client. Which
instruction should the nurse give the client about this medication?
1
Prolonged use can cause dark concentrated urine.
