FUNDAMENTAL HESI 2026 UPDATED REVIEWS
QUESTIONS AND ANSWERS SURE A+
✔✔The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the
client starts to fall. Which is the priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. - ✔✔D
Rationale: Option D is the most prudent intervention and is the priority nursing action to
prevent injury to the client and the nurse. Lowering the client to the floor should be done
when the client cannot support his own weight. The client should be placed in a bed or
chair only when sufficient help is available to prevent injury. Option A is important but
should be done after the client is in a safe position. Because the client is not supporting
himself, option B is impractical. Option C is likely to cause chaos on the unit and might
alarm the other clients.
,✔✔The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is
128 mEq/L. The nurse should be alert for which findings? (Select all that apply.)
A.
Weakness in the hands and feet
B.
+1 reflexes to the patella
C.
Headache
D.
Muscle twitching
E.
Nausea
F.
Facial redness - ✔✔A, B, C, E
Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle
twitching and facial redness.
✔✔The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts
were made prior to obtaining the sample with the tourniquet in place for nearly 5
minutes. Which laboratory finding would the nurse suspect is inaccurate related to the
prolonged tourniquet placement?
A.
Na 148 mEq/L
B.
K 5.3 mEq/L
C.
Cl 102 mEq/L
D.
Ca 9.3 mg/dL - ✔✔B
Rationale: Prolonged tourniquet placement can cause accumulation of potassium,
skewing the result upward. The sodium level is also high, but that is not related to the
blood draw. The chloride and calcium levels are normal.
✔✔The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the
nurse bring to the attention of the healthcare provider?
A.
Temperature: 97.5°F/36.4°C
B.
Pulse: 80 beats/min
C.
Respirations: 26 breaths/min
D.
Blood pressure: 90/53 mm Hg - ✔✔B
Rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is
below the normal range. The remaining vital signs are within the normal limits for a 1-
year-old.
,✔✔The clinic nurse is reviewing an antibiotic medication prescribed to a client with a
urinary tract infection. What instructions will the nurse include in the client's teaching?
(Select all that apply.)
A.
Take all of the medication as prescribed, especially when you start feeling better.
B.
Take the medication with 8 ounce/240 mL of water.
C.
Call poison control if you start itching, develop hives, or have difficulty breathing.
D.
Keep this medication out of the reach of small children, preferably in a locked cabinet.
E.
Call your healthcare provider (HCP) when your symptoms subside. - ✔✔A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics.
The client needs to take the full course of antibiotics to achieve the maximum effect.
Drinking a glass of water will help keep the body hydrated. All medication should be
kept out of reach, preferably in a locked cabinet. The client needs to call the health care
provider in the event of an allergic reaction to the antibiotic. The medication is
prescribed to treat the infection. There is no need to notify the HCP when the
medication is having the desired effects.
✔✔The nurse is aware that malnutrition is a common problem among clients served by
a community health clinic for the homeless. Which laboratory value is the most reliable
indicator of chronic protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level - ✔✔A
Rationale: Long-term protein deficiency is required to cause significantly lowered serum
albumin levels. Albumin is made by the liver only when adequate amounts of amino
acids (from protein breakdown) are available. Albumin has a long half-life, so acute
protein loss does not significantly alter serum levels. Option B is a serum protein with a
half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C
and D are not clinical measures of protein malnutrition.
✔✔A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse
take first?
A.
Tell the client that the blood pressure is high and that the reading needs to be verified
by another nurse.
B.
, Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication.
C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase arm
comfort.
D.
Compare the current reading with the client's previously documented blood pressure
readings. - ✔✔D
Rationale: Comparing this reading with previous readings will provide information about
what is normal for this client; this action should be taken first. Option A might
unnecessarily alarm the client. Option B is premature. Further assessment is needed to
determine if the reading is abnormal for this client. Option C could falsely decrease the
reading and is not the correct procedure for obtaining a blood pressure reading.
✔✔The nurse comes upon an automobile accident involving many cars. Which victim
should the nurse see first?
A.
The victim who is not breathing and does not have a pulse
B.
The victim who is bleeding out of both the ears, and the nose and mouth, with a blank
stare
C.
The victim who is heavily bleeding bright red blood from a thigh wound
D.
The victim who is crying, complaining of arm pain, and no other apparent injuries - ✔✔C
Rationale: The client hemorrhaging from the leg wound is the priority as of the severely
injured clients; the nurse can help the client by tying off the leg above the injury and/or
applying pressure to the wound site. When there is only one health care provider on the
scene, the nurse must provide care to those who are most likely to survive. The client
without a pulse and respirations is dead. The client with bleeding from the ears, nose,
and mouth, with a blank stare, likely has severe head trauma. The victim with arm pain
and crying is the lowest priority.
✔✔The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When
viewing the consent form, the nurse notes the surgeon's signature, but not the client's
signature. What steps must the nurse take? (Select all that apply.)
A.
Call the surgeon.
B.
Ask the client, "Did your surgeon explain the procedure to you?"
C.
Have the client's spouse sign the form.
D.
Ask the client, "Do you have any questions?"
E.
Witness the signature.
QUESTIONS AND ANSWERS SURE A+
✔✔The nurse is assisting a client to the bathroom. When the client is 5 feet from the
bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the
client starts to fall. Which is the priority action for the nurse to take?
A.
Check the client's carotid pulse.
B.
Encourage the client to get to the toilet.
C.
In a loud voice, call for help.
D.
Gently lower the client to the floor. - ✔✔D
Rationale: Option D is the most prudent intervention and is the priority nursing action to
prevent injury to the client and the nurse. Lowering the client to the floor should be done
when the client cannot support his own weight. The client should be placed in a bed or
chair only when sufficient help is available to prevent injury. Option A is important but
should be done after the client is in a safe position. Because the client is not supporting
himself, option B is impractical. Option C is likely to cause chaos on the unit and might
alarm the other clients.
,✔✔The nurse is reviewing a client's lab results from 2 hours ago. The sodium level is
128 mEq/L. The nurse should be alert for which findings? (Select all that apply.)
A.
Weakness in the hands and feet
B.
+1 reflexes to the patella
C.
Headache
D.
Muscle twitching
E.
Nausea
F.
Facial redness - ✔✔A, B, C, E
Rationale: The client is hyponatremic. All are signs of hyponatremia except muscle
twitching and facial redness.
✔✔The nurse is drawing a blood sample from the client's basilic vein. Multiple attempts
were made prior to obtaining the sample with the tourniquet in place for nearly 5
minutes. Which laboratory finding would the nurse suspect is inaccurate related to the
prolonged tourniquet placement?
A.
Na 148 mEq/L
B.
K 5.3 mEq/L
C.
Cl 102 mEq/L
D.
Ca 9.3 mg/dL - ✔✔B
Rationale: Prolonged tourniquet placement can cause accumulation of potassium,
skewing the result upward. The sodium level is also high, but that is not related to the
blood draw. The chloride and calcium levels are normal.
✔✔The clinic nurse is taking the vital signs of a 1-year-old. Which finding should the
nurse bring to the attention of the healthcare provider?
A.
Temperature: 97.5°F/36.4°C
B.
Pulse: 80 beats/min
C.
Respirations: 26 breaths/min
D.
Blood pressure: 90/53 mm Hg - ✔✔B
Rationale: A normal pulse rate for a 1-year-old is 90 to 130. This child's heart beat is
below the normal range. The remaining vital signs are within the normal limits for a 1-
year-old.
,✔✔The clinic nurse is reviewing an antibiotic medication prescribed to a client with a
urinary tract infection. What instructions will the nurse include in the client's teaching?
(Select all that apply.)
A.
Take all of the medication as prescribed, especially when you start feeling better.
B.
Take the medication with 8 ounce/240 mL of water.
C.
Call poison control if you start itching, develop hives, or have difficulty breathing.
D.
Keep this medication out of the reach of small children, preferably in a locked cabinet.
E.
Call your healthcare provider (HCP) when your symptoms subside. - ✔✔A, B, D
Rationale: Once symptoms subside, it is sometime hard to remember to take antibiotics.
The client needs to take the full course of antibiotics to achieve the maximum effect.
Drinking a glass of water will help keep the body hydrated. All medication should be
kept out of reach, preferably in a locked cabinet. The client needs to call the health care
provider in the event of an allergic reaction to the antibiotic. The medication is
prescribed to treat the infection. There is no need to notify the HCP when the
medication is having the desired effects.
✔✔The nurse is aware that malnutrition is a common problem among clients served by
a community health clinic for the homeless. Which laboratory value is the most reliable
indicator of chronic protein malnutrition?
A.
Low serum albumin level
B.
Low serum transferrin level
C.
High hemoglobin level
D.
High cholesterol level - ✔✔A
Rationale: Long-term protein deficiency is required to cause significantly lowered serum
albumin levels. Albumin is made by the liver only when adequate amounts of amino
acids (from protein breakdown) are available. Albumin has a long half-life, so acute
protein loss does not significantly alter serum levels. Option B is a serum protein with a
half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C
and D are not clinical measures of protein malnutrition.
✔✔A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse
take first?
A.
Tell the client that the blood pressure is high and that the reading needs to be verified
by another nurse.
B.
, Contact the health care provider to report the reading and obtain a prescription for an
antihypertensive medication.
C.
Replace the cuff with a larger one to ensure an ample fit for the client to increase arm
comfort.
D.
Compare the current reading with the client's previously documented blood pressure
readings. - ✔✔D
Rationale: Comparing this reading with previous readings will provide information about
what is normal for this client; this action should be taken first. Option A might
unnecessarily alarm the client. Option B is premature. Further assessment is needed to
determine if the reading is abnormal for this client. Option C could falsely decrease the
reading and is not the correct procedure for obtaining a blood pressure reading.
✔✔The nurse comes upon an automobile accident involving many cars. Which victim
should the nurse see first?
A.
The victim who is not breathing and does not have a pulse
B.
The victim who is bleeding out of both the ears, and the nose and mouth, with a blank
stare
C.
The victim who is heavily bleeding bright red blood from a thigh wound
D.
The victim who is crying, complaining of arm pain, and no other apparent injuries - ✔✔C
Rationale: The client hemorrhaging from the leg wound is the priority as of the severely
injured clients; the nurse can help the client by tying off the leg above the injury and/or
applying pressure to the wound site. When there is only one health care provider on the
scene, the nurse must provide care to those who are most likely to survive. The client
without a pulse and respirations is dead. The client with bleeding from the ears, nose,
and mouth, with a blank stare, likely has severe head trauma. The victim with arm pain
and crying is the lowest priority.
✔✔The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When
viewing the consent form, the nurse notes the surgeon's signature, but not the client's
signature. What steps must the nurse take? (Select all that apply.)
A.
Call the surgeon.
B.
Ask the client, "Did your surgeon explain the procedure to you?"
C.
Have the client's spouse sign the form.
D.
Ask the client, "Do you have any questions?"
E.
Witness the signature.
