HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3
days. She states, "I have been told that it is harmful to bathe during my period." Which action
should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client. - ✔✔✔-D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
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. - ✔✔✔-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.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and
states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which
intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client. - ✔✔✔-D
,HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide
concrete information about the schedule. Option A is contraindicated if the client wants to
continue smoking. Option B is insufficient to encourage a trusting relationship with the client.
Option C is preferential for this client only and is inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ✔✔✔-D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube in
the stomach before instilling the medications. To prevent immediate removal of the instilled
medications and allow absorption, the tube should be clamped for a period of time before
reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client
instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ✔✔✔-A
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production
of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections.
Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in
urinary incontinence if the client is sedated and does not awaken to void.
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.
,HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
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. - ✔✔✔-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 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.
A community hospital is opening a mental health services department. Which document should
the nurse use to develop the unit's nursing guidelines?
A. Americans with Disabilities Act of 1990
B. ANA Code of Ethics with Interpretative Statements
C. ANA's Scope and Standards of Nursing Practice
D. Patient's Bill of Rights of 1990 - ✔✔✔-C
, HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves
to direct the philosophy and standards of psychiatric nursing practice. Options A and D define
the client's rights. Option B provides ethical guidelines for nursing.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's
advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the
nurse to provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. - ✔✔✔-C
Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of
Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to
be as effective as cranberry juice in preventing UTIs.
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and
restless. Which action by the nurse is best?
A. Determine the client's usual bedtime routine and include these rituals in the plan of care as
safety allows.
B. Instruct the UAP not to wake the client under any circumstances during the night.
C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8
hours.
D. Encourage the client to avoid pain medication during the day, which might increase daytime
napping. - ✔✔✔-A
Rationale: Including habitual rituals that do not interfere with the client's care or safety may
allow the client to go to sleep faster and increase the quality of care. Options B, C, and D
decrease the client's standard of care and compromise safety.
A male client is laughing at a television program with his wife when the evening nurse enters
the room. He says his foot is hurting and he would like a pain pill. How should the nurse
respond?
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3
days. She states, "I have been told that it is harmful to bathe during my period." Which action
should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client. - ✔✔✔-D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
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. - ✔✔✔-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.
A client becomes angry while waiting for a supervised break to smoke a cigarette outside and
states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which
intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client. - ✔✔✔-D
,HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide
concrete information about the schedule. Option A is contraindicated if the client wants to
continue smoking. Option B is insufficient to encourage a trusting relationship with the client.
Option C is preferential for this client only and is inconsistent with unit rules.
A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ✔✔✔-D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube in
the stomach before instilling the medications. To prevent immediate removal of the instilled
medications and allow absorption, the tube should be clamped for a period of time before
reconnecting the suction.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client
instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ✔✔✔-A
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production
of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections.
Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in
urinary incontinence if the client is sedated and does not awaken to void.
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.
,HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
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. - ✔✔✔-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 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.
A community hospital is opening a mental health services department. Which document should
the nurse use to develop the unit's nursing guidelines?
A. Americans with Disabilities Act of 1990
B. ANA Code of Ethics with Interpretative Statements
C. ANA's Scope and Standards of Nursing Practice
D. Patient's Bill of Rights of 1990 - ✔✔✔-C
, HESI – Fundamentals 2025-2026 Proven Questions + Detailed Answers
Rationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursing serves
to direct the philosophy and standards of psychiatric nursing practice. Options A and D define
the client's rights. Option B provides ethical guidelines for nursing.
A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's
advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the
nurse to provide?
A. Orange juice has vitamin C that deters bacterial growth.
B. Apple juice is the most useful in acidifying the urine.
C. Cranberry juice stops pathogens' adherence to the bladder.
D. Grapefruit juice increases absorption of most antibiotics. - ✔✔✔-C
Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of
Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to
be as effective as cranberry juice in preventing UTIs.
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and
restless. Which action by the nurse is best?
A. Determine the client's usual bedtime routine and include these rituals in the plan of care as
safety allows.
B. Instruct the UAP not to wake the client under any circumstances during the night.
C. Place a "Do Not Disturb" sign on the door and change assessments from every 4 to every 8
hours.
D. Encourage the client to avoid pain medication during the day, which might increase daytime
napping. - ✔✔✔-A
Rationale: Including habitual rituals that do not interfere with the client's care or safety may
allow the client to go to sleep faster and increase the quality of care. Options B, C, and D
decrease the client's standard of care and compromise safety.
A male client is laughing at a television program with his wife when the evening nurse enters
the room. He says his foot is hurting and he would like a pain pill. How should the nurse
respond?
