PN HESI FUNDAMENTALS EXAMS 2 EXAM PREP
2026 PRACTICE SOLUTION STUDY GUIDE
◉ A client in a long-term care facility reports to the nurse that he
has not had a bowel movement in 2 days. Which intervention should
the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at
mealtimes.
B. Notify the health care provider and request a prescription for a
large-volume enema.
C. Assess the client's medical record to determine the client's normal
bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce
glasses per day. Answer: C
Rationale: This client may not routinely have a daily bowel
movement, so the nurse should first assess this client's normal
bowel habits before attempting any intervention. Option A, B, or D
may then be implemented, if warranted.
◉ A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which instruction
is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
,C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. Answer: B
Rationale: The most important teaching is to change positions
frequently because pressure is the most significant factor related to
the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce
further risk. Option D is an intervention of last resort because this
will be very expensive for the client.
◉ Urinary catheterization is prescribed for a postoperative female
client who has been unable to void for 8 hours. The nurse inserts the
catheter, but no urine is seen in the tubing. Which action will the
nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction. Answer:
C
Rationale: It is likely that the first catheter is in the vagina, rather
than the bladder. Leaving the first catheter in place will help locate
the meatus when attempting the second catheterization. The client
should have at least 240 mL of urine after 8 hours. Option A does not
resolve the problem. Option B will not change the location of the
catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract
obstruction if the catheter could be easily inserted.
,◉ The mental health nurse plans to discuss a client's depression
with the health care provider in the emergency department. There
are two clients sitting across from the emergency department desk.
Which nursing action is best?
A. Only refer to the client by gender.
B. Identify the client only by age.
C. Avoid using the client's name.
D. Discuss the client another time. Answer: D
Rationale: The best nursing action is to discuss the client another
time. Confidentiality must be observed at all times, so the nurse
should not discuss the client when the conversation can be
overheard by others. Details can identify the client when referring to
the client by gender or age, even when not using the client's name.
◉ The nurse is teaching a client how to perform progressive muscle
relaxation techniques to relieve insomnia. A week later the client
reports that he is still unable to sleep, despite following the same
routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is
achieved.
D. Ask the client to describe the routine he is currently following.
Answer: D
, Rationale: The nurse should first evaluate whether the client has
been adhering to the original instructions. A verbal report of the
client's routine will provide more specific information than the
client's written diary. The nurse can then determine which changes
need to be made. The routine practiced by the client is clearly
unsuccessful, so encouragement alone is insufficient.
◉ Ten minutes after signing an operative permit for a fractured hip,
an older client states, "The aliens will be coming to get me soon!"
and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client's family to co-sign the operative permit. Answer: B
Rationale: This statement may indicate that the client is confused.
Informed consent must be provided by a mentally competent
individual, so the nurse should further assess the client's neurologic
status to be sure that the client understands and can legally provide
consent for surgery. Option A does not provide sufficient follow-up.
If the nurse determines that the client is confused, the surgeon must
be notified and permission obtained from the next of kin.
◉ A nurse is working in an occupational health clinic when an
employee walks in and states that he was struck by lightning while
working in a truck bed. The client is alert but reports feeling faint.
Which assessment will the nurse perform first?
2026 PRACTICE SOLUTION STUDY GUIDE
◉ A client in a long-term care facility reports to the nurse that he
has not had a bowel movement in 2 days. Which intervention should
the nurse implement first?
A. Instruct the caregiver to offer a glass of warm prune juice at
mealtimes.
B. Notify the health care provider and request a prescription for a
large-volume enema.
C. Assess the client's medical record to determine the client's normal
bowel pattern.
D. Instruct the caregiver to increase the client's fluids to five 8-ounce
glasses per day. Answer: C
Rationale: This client may not routinely have a daily bowel
movement, so the nurse should first assess this client's normal
bowel habits before attempting any intervention. Option A, B, or D
may then be implemented, if warranted.
◉ A 65-year-old client who attends an adult daycare program and is
wheelchair-mobile has redness in the sacral area. Which instruction
is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
,C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair. Answer: B
Rationale: The most important teaching is to change positions
frequently because pressure is the most significant factor related to
the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce
further risk. Option D is an intervention of last resort because this
will be very expensive for the client.
◉ Urinary catheterization is prescribed for a postoperative female
client who has been unable to void for 8 hours. The nurse inserts the
catheter, but no urine is seen in the tubing. Which action will the
nurse take next?
A. Clamp the catheter and recheck it in 60 minutes.
B. Pull the catheter back 3 inches and redirect upward.
C. Leave the catheter in place and reattempt with another catheter.
D. Notify the health care provider of a possible obstruction. Answer:
C
Rationale: It is likely that the first catheter is in the vagina, rather
than the bladder. Leaving the first catheter in place will help locate
the meatus when attempting the second catheterization. The client
should have at least 240 mL of urine after 8 hours. Option A does not
resolve the problem. Option B will not change the location of the
catheter unless it is completely removed, in which case a new
catheter must be used. There is no evidence of a urinary tract
obstruction if the catheter could be easily inserted.
,◉ The mental health nurse plans to discuss a client's depression
with the health care provider in the emergency department. There
are two clients sitting across from the emergency department desk.
Which nursing action is best?
A. Only refer to the client by gender.
B. Identify the client only by age.
C. Avoid using the client's name.
D. Discuss the client another time. Answer: D
Rationale: The best nursing action is to discuss the client another
time. Confidentiality must be observed at all times, so the nurse
should not discuss the client when the conversation can be
overheard by others. Details can identify the client when referring to
the client by gender or age, even when not using the client's name.
◉ The nurse is teaching a client how to perform progressive muscle
relaxation techniques to relieve insomnia. A week later the client
reports that he is still unable to sleep, despite following the same
routine every night. Which action should the nurse take first?
A. Instruct the client to add regular exercise as a daily routine.
B. Determine if the client has been keeping a sleep diary.
C. Encourage the client to continue the routine until sleep is
achieved.
D. Ask the client to describe the routine he is currently following.
Answer: D
, Rationale: The nurse should first evaluate whether the client has
been adhering to the original instructions. A verbal report of the
client's routine will provide more specific information than the
client's written diary. The nurse can then determine which changes
need to be made. The routine practiced by the client is clearly
unsuccessful, so encouragement alone is insufficient.
◉ Ten minutes after signing an operative permit for a fractured hip,
an older client states, "The aliens will be coming to get me soon!"
and falls asleep. Which action should the nurse implement next?
A. Make the client comfortable and allow the client to sleep.
B. Assess the client's neurologic status.
C. Notify the surgeon about the comment.
D. Ask the client's family to co-sign the operative permit. Answer: B
Rationale: This statement may indicate that the client is confused.
Informed consent must be provided by a mentally competent
individual, so the nurse should further assess the client's neurologic
status to be sure that the client understands and can legally provide
consent for surgery. Option A does not provide sufficient follow-up.
If the nurse determines that the client is confused, the surgeon must
be notified and permission obtained from the next of kin.
◉ A nurse is working in an occupational health clinic when an
employee walks in and states that he was struck by lightning while
working in a truck bed. The client is alert but reports feeling faint.
Which assessment will the nurse perform first?
