HESI FUNDAMENTALS PRACTICE TEST 2
COMPREHENSIVE STUDY GUIDE 2026 BASIC
NURSING CONCEPTS AND FUNDAMENTAL
CARE PRINCIPLES
◉ 65.What intervention should the nurse include in the plan of care
for a client who is being treated with an Unna's paste boot for leg
ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste
boot.
B. Apply dressing to wound area before applying the Unna's paste
boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing.
Answer: The Unna's paste boot becomes rigid after it dries, so it is
important to check distally for adequate circulation (A). Kerlix is
often wrapped around the outside of the boot and an ace bandage
may be used to cover both, but no bandage should be put under it
(B). The Unna's paste boot should be applied from the foot and
wrapped towards the knee (C). The Unna's paste boot acts as a
sterile dressing, and should not be removed q8h. Weekly removal is
reasonable (D).
Correct
Answer: A
,◉ 66.A 75-year-old client who has a history of end stage renal
failure and advanced lung cancer, recently had a stroke. Two days
ago the healthcare provider discontinued the client's dialysis
treatments, stating that death is inevitable, but the client is
disoriented and will not sign a DNR directive. What is the priority
nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions.
Answer: When death is impending, it is essential for the nurse to
determine who is legally empowered to make decisions regarding
the use of life-saving measures for the client (D). (A) will be
abnormal and will worsen without dialysis, so are not of immediate
concern. (B) may help improve the client's quality of life prior to
death, but is of less immediacy than determining whether actions
should be taken to save a client's life. If the nurse remains unable to
determine who is empowered to make decisions in this situation, the
nurse may choose to contact the ethics committee (C) for a
resolution.
Correct
Answer: D
,◉ 67.The charge nurse assigns a nursing procedure to a new staff
nurse who has not previously performed the procedure. What action
is most important for the new staff nurse to take?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience.
Answer: According to states' nurse practice acts, it is the
responsibility of the nurse to function within the scope of
competency (D), and in this case safe nursing practice constitutes
refusal to perform the procedure because of a lack of experience.
Although state mandates, agency policies, and continued education
and experience identify tasks that are within the scope of nursing
practice, nurses should first refuse to perform tasks that are beyond
their proficiency, and then pursue opportunities to enhance their
competency (A, B, and C).
Correct
Answer: D
◉ 68.Before administering a client's medication, the nurse assesses
a change in the client's condition and decides to withhold the
medication until consulting with the healthcare provider. After
consultation with the healthcare provider, the dose of the
medication is changed and the nurse administers the newly
prescribed dose an hour later than the originally scheduled time.
, What action should the nurse implement in response to this
situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record.
Answer: The nurse took the correct action and should document the
events that occurred in the nurses' notes (C). (A) did not occur and
(B) is not indicated. The medication administration record is part of
the client's medical record and should be placed in the chart, (D)
when no longer current.
Correct
Answer: C
◉ 69.On the third postoperative day following thoracic surgery, a
client reports feeling constipated. Which intervention should the
nurse implement to promote bowel elimination?
A. Remind the client to turn every two hours while lying in bed.
B. Provide warm prune juice before the client goes to bed at night.
C. Teach the client to splint the incision while walking to the
bathroom.
D. Administer an analgesic before the client attempts to defecate.
Answer: Prune juice is a natural laxative that stimulates peristalsis,
and warming the prune juice (B) facilitates peristalsis. (A) is also
COMPREHENSIVE STUDY GUIDE 2026 BASIC
NURSING CONCEPTS AND FUNDAMENTAL
CARE PRINCIPLES
◉ 65.What intervention should the nurse include in the plan of care
for a client who is being treated with an Unna's paste boot for leg
ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste
boot.
B. Apply dressing to wound area before applying the Unna's paste
boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing.
Answer: The Unna's paste boot becomes rigid after it dries, so it is
important to check distally for adequate circulation (A). Kerlix is
often wrapped around the outside of the boot and an ace bandage
may be used to cover both, but no bandage should be put under it
(B). The Unna's paste boot should be applied from the foot and
wrapped towards the knee (C). The Unna's paste boot acts as a
sterile dressing, and should not be removed q8h. Weekly removal is
reasonable (D).
Correct
Answer: A
,◉ 66.A 75-year-old client who has a history of end stage renal
failure and advanced lung cancer, recently had a stroke. Two days
ago the healthcare provider discontinued the client's dialysis
treatments, stating that death is inevitable, but the client is
disoriented and will not sign a DNR directive. What is the priority
nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions.
Answer: When death is impending, it is essential for the nurse to
determine who is legally empowered to make decisions regarding
the use of life-saving measures for the client (D). (A) will be
abnormal and will worsen without dialysis, so are not of immediate
concern. (B) may help improve the client's quality of life prior to
death, but is of less immediacy than determining whether actions
should be taken to save a client's life. If the nurse remains unable to
determine who is empowered to make decisions in this situation, the
nurse may choose to contact the ethics committee (C) for a
resolution.
Correct
Answer: D
,◉ 67.The charge nurse assigns a nursing procedure to a new staff
nurse who has not previously performed the procedure. What action
is most important for the new staff nurse to take?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience.
Answer: According to states' nurse practice acts, it is the
responsibility of the nurse to function within the scope of
competency (D), and in this case safe nursing practice constitutes
refusal to perform the procedure because of a lack of experience.
Although state mandates, agency policies, and continued education
and experience identify tasks that are within the scope of nursing
practice, nurses should first refuse to perform tasks that are beyond
their proficiency, and then pursue opportunities to enhance their
competency (A, B, and C).
Correct
Answer: D
◉ 68.Before administering a client's medication, the nurse assesses
a change in the client's condition and decides to withhold the
medication until consulting with the healthcare provider. After
consultation with the healthcare provider, the dose of the
medication is changed and the nurse administers the newly
prescribed dose an hour later than the originally scheduled time.
, What action should the nurse implement in response to this
situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record.
Answer: The nurse took the correct action and should document the
events that occurred in the nurses' notes (C). (A) did not occur and
(B) is not indicated. The medication administration record is part of
the client's medical record and should be placed in the chart, (D)
when no longer current.
Correct
Answer: C
◉ 69.On the third postoperative day following thoracic surgery, a
client reports feeling constipated. Which intervention should the
nurse implement to promote bowel elimination?
A. Remind the client to turn every two hours while lying in bed.
B. Provide warm prune juice before the client goes to bed at night.
C. Teach the client to splint the incision while walking to the
bathroom.
D. Administer an analgesic before the client attempts to defecate.
Answer: Prune juice is a natural laxative that stimulates peristalsis,
and warming the prune juice (B) facilitates peristalsis. (A) is also
