HESI FUNDAMENTALS EXAM
SPRING 2025 TEST BANK UPDATED
100% CORRECT
1. An African-American grandmother tells the nurse that her 4-year-old grandson
is suffering with "miseries." Based on this statement, which focused assessment
should the nurse conduct?
A. Ask about the child's sleep patterns
B. Inquire about the source and type of pain
C. Assess the child's appetite and fluid intake
D. Evaluate the child's bowel and bladder function
Answer: B
Rationale: "Miseries" is a cultural term often used to describe generalized
discomfort or pain. The nurse should explore the source and characteristics of the
pain.
2. The nurse is assessing the nutritional status of several clients. Which client has
the greatest nutritional need for additional intake of protein?
A. A 25-year-old male athlete training for a marathon
B. A 60-year-old woman with osteoporosis
C. A lactating woman nursing her 3-day-old infant
D. A 10-year-old child recovering from a tonsillectomy
Answer: C
Rationale: Lactating women have increased protein requirements to support milk
production and tissue repair after childbirth.
3. An older client who is a resident in a long-term care facility has been bedridden
for a week. Which finding should the nurse identify as a client risk factor for
pressure ulcers?
A. Dry, intact skin on the sacrum
B. Rashes in the axillary, groin, and skin fold regions
,C. Normal serum albumin level of 3.8 g/dL
D. Ability to reposition self independently
Answer: B
Rationale: Moisture from perspiration or incontinence in skin folds increases the
risk of skin breakdown and pressure ulcers.
4. A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for
surgery the next day. Which question is most important for the nurse to include
during the preoperative assessment?
A. "What vitamin and mineral supplements do you take?"
B. "Have you had any previous surgeries?"
C. "Do you have any allergies to medications?"
D. "What is your typical daily fluid intake?"
Answer: A
Rationale: Herbal and vitamin supplements can interact with anesthesia and
increase bleeding risk; it is essential to assess supplement use preoperatively.
5. Secobarbital 150 mg is prescribed at bedtime for a male client who is scheduled
for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How
many tablets should the nurse administer? (Enter the numerical value only. If
rounding is required, round to the nearest tenth.)
Answer: 1.5
*Rationale: 0.1 gram = 100 mg; 150 mg ÷ 100 mg = 1.5 tablets.*
6. A hospitalized male client is receiving nasogastric tube feedings via a small-bore
tube and a continuous pump infusion. He reports that he had a bad bout of severe
coughing a few minutes ago, but feels fine now. Which action is best for the nurse
to take?
A. Stop the feeding and notify the healthcare provider immediately
B. Auscultate for bowel sounds and resume the feeding
C. After clearing the tube with 30 ml of air, check the pH of the fluid withdrawn
from the tube
D. Flush the tube with 50 ml of water and increase the infusion rate
,Answer: C
Rationale: Coughing may have displaced the tube; checking pH of aspirated fluid
helps verify gastric placement before resuming feeding.
7. The nurse is preparing to insert an indwelling urinary catheter for a female
client. Which technique is correct?
A. Clean the meatus from back to front
B. Insert the catheter 2–3 inches until urine flows
C. Inflate the balloon before inserting the catheter
D. Use sterile gloves and a sterile field
Answer: D
Rationale: Sterile technique is required for catheter insertion to prevent infection.
8. A client with a new colostomy asks the nurse, "Will I ever be able to control my
bowel movements again?" Which response is most appropriate?
A. "You will not have control because the colostomy is permanent."
B. "With irrigation, you may be able to regulate your bowel movements."
C. "You will need to wear a pouch at all times."
D. "Most people eventually regain normal control."
Answer: B
Rationale: Colostomy irrigation can help establish a predictable pattern of
elimination, allowing the client to wear a smaller appliance or cap between
irrigations.
9. A client is receiving a blood transfusion and reports chills and back pain. What
is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion and start normal saline
C. Administer acetaminophen as ordered
D. Notify the healthcare provider
Answer: B
Rationale: Chills and back pain suggest a hemolytic transfusion reaction; the
transfusion must be stopped immediately and saline infused to maintain IV access.
, 10. The nurse is assessing a client's risk for falls. Which finding places the client at
highest risk?
A. Age 75 years
B. History of a fall 3 months ago
C. Taking a beta-blocker for hypertension
D. Wearing bifocal glasses
Answer: B
Rationale: A prior fall is the strongest predictor of future falls.
11. A client with a new diagnosis of type 2 diabetes asks the nurse, "Why do I have
to check my blood sugar if I am not taking insulin?" Which response is best?
A. "Blood sugar monitoring helps you learn how food and activity affect your
levels."
B. "It is required by your insurance company."
C. "You will eventually need insulin, so it is good to practice now."
D. "Your doctor wants to make sure you are following your diet."
Answer: A
Rationale: Self-monitoring of blood glucose provides feedback on the effects of
diet, exercise, and oral medications.
12. The nurse is teaching a client about using a patient-controlled analgesia (PCA)
pump. Which statement by the client indicates understanding?
A. "My family can push the button if I am sleeping."
B. "I will push the button every hour to stay ahead of the pain."
C. "The pump will not let me overdose on pain medication."
D. "I should wait until the pain is severe before pushing the button."
Answer: C
Rationale: PCA pumps have a lockout interval to prevent overdose, ensuring
patient safety.
SPRING 2025 TEST BANK UPDATED
100% CORRECT
1. An African-American grandmother tells the nurse that her 4-year-old grandson
is suffering with "miseries." Based on this statement, which focused assessment
should the nurse conduct?
A. Ask about the child's sleep patterns
B. Inquire about the source and type of pain
C. Assess the child's appetite and fluid intake
D. Evaluate the child's bowel and bladder function
Answer: B
Rationale: "Miseries" is a cultural term often used to describe generalized
discomfort or pain. The nurse should explore the source and characteristics of the
pain.
2. The nurse is assessing the nutritional status of several clients. Which client has
the greatest nutritional need for additional intake of protein?
A. A 25-year-old male athlete training for a marathon
B. A 60-year-old woman with osteoporosis
C. A lactating woman nursing her 3-day-old infant
D. A 10-year-old child recovering from a tonsillectomy
Answer: C
Rationale: Lactating women have increased protein requirements to support milk
production and tissue repair after childbirth.
3. An older client who is a resident in a long-term care facility has been bedridden
for a week. Which finding should the nurse identify as a client risk factor for
pressure ulcers?
A. Dry, intact skin on the sacrum
B. Rashes in the axillary, groin, and skin fold regions
,C. Normal serum albumin level of 3.8 g/dL
D. Ability to reposition self independently
Answer: B
Rationale: Moisture from perspiration or incontinence in skin folds increases the
risk of skin breakdown and pressure ulcers.
4. A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for
surgery the next day. Which question is most important for the nurse to include
during the preoperative assessment?
A. "What vitamin and mineral supplements do you take?"
B. "Have you had any previous surgeries?"
C. "Do you have any allergies to medications?"
D. "What is your typical daily fluid intake?"
Answer: A
Rationale: Herbal and vitamin supplements can interact with anesthesia and
increase bleeding risk; it is essential to assess supplement use preoperatively.
5. Secobarbital 150 mg is prescribed at bedtime for a male client who is scheduled
for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How
many tablets should the nurse administer? (Enter the numerical value only. If
rounding is required, round to the nearest tenth.)
Answer: 1.5
*Rationale: 0.1 gram = 100 mg; 150 mg ÷ 100 mg = 1.5 tablets.*
6. A hospitalized male client is receiving nasogastric tube feedings via a small-bore
tube and a continuous pump infusion. He reports that he had a bad bout of severe
coughing a few minutes ago, but feels fine now. Which action is best for the nurse
to take?
A. Stop the feeding and notify the healthcare provider immediately
B. Auscultate for bowel sounds and resume the feeding
C. After clearing the tube with 30 ml of air, check the pH of the fluid withdrawn
from the tube
D. Flush the tube with 50 ml of water and increase the infusion rate
,Answer: C
Rationale: Coughing may have displaced the tube; checking pH of aspirated fluid
helps verify gastric placement before resuming feeding.
7. The nurse is preparing to insert an indwelling urinary catheter for a female
client. Which technique is correct?
A. Clean the meatus from back to front
B. Insert the catheter 2–3 inches until urine flows
C. Inflate the balloon before inserting the catheter
D. Use sterile gloves and a sterile field
Answer: D
Rationale: Sterile technique is required for catheter insertion to prevent infection.
8. A client with a new colostomy asks the nurse, "Will I ever be able to control my
bowel movements again?" Which response is most appropriate?
A. "You will not have control because the colostomy is permanent."
B. "With irrigation, you may be able to regulate your bowel movements."
C. "You will need to wear a pouch at all times."
D. "Most people eventually regain normal control."
Answer: B
Rationale: Colostomy irrigation can help establish a predictable pattern of
elimination, allowing the client to wear a smaller appliance or cap between
irrigations.
9. A client is receiving a blood transfusion and reports chills and back pain. What
is the nurse's priority action?
A. Slow the transfusion rate
B. Stop the transfusion and start normal saline
C. Administer acetaminophen as ordered
D. Notify the healthcare provider
Answer: B
Rationale: Chills and back pain suggest a hemolytic transfusion reaction; the
transfusion must be stopped immediately and saline infused to maintain IV access.
, 10. The nurse is assessing a client's risk for falls. Which finding places the client at
highest risk?
A. Age 75 years
B. History of a fall 3 months ago
C. Taking a beta-blocker for hypertension
D. Wearing bifocal glasses
Answer: B
Rationale: A prior fall is the strongest predictor of future falls.
11. A client with a new diagnosis of type 2 diabetes asks the nurse, "Why do I have
to check my blood sugar if I am not taking insulin?" Which response is best?
A. "Blood sugar monitoring helps you learn how food and activity affect your
levels."
B. "It is required by your insurance company."
C. "You will eventually need insulin, so it is good to practice now."
D. "Your doctor wants to make sure you are following your diet."
Answer: A
Rationale: Self-monitoring of blood glucose provides feedback on the effects of
diet, exercise, and oral medications.
12. The nurse is teaching a client about using a patient-controlled analgesia (PCA)
pump. Which statement by the client indicates understanding?
A. "My family can push the button if I am sleeping."
B. "I will push the button every hour to stay ahead of the pain."
C. "The pump will not let me overdose on pain medication."
D. "I should wait until the pain is severe before pushing the button."
Answer: C
Rationale: PCA pumps have a lockout interval to prevent overdose, ensuring
patient safety.
