HESI PN FUNDAMENTALS EXAM VERSION 2UPDATED
AND REVISED IN 2025-2026 DECEMBER
The nurse observes an unlicensed assistive personnel (UAP) taking a
client's blood pressure with a cuff that is too small, but the blood
pressure reading obtained is within the client's usual range. What
action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
B. Reassess the client's blood pressure using a larger cuff.
The most important action is to ensure that an accurate BP reading is
obtained. The nurse should reassess the BP with the correct size cuff (B).
Reassessment should not be postponed (A). Though (C and D) are likely
indicated, these actions do not have the priority of (B).
Twenty minutes after beginning a heat application, the client states
that the heating pad no longer feels warm enough. What is the best
response by the nurse?
A. That means you have derived the maximum benefit, and the heat
can be removed.
B. Your blood vessels are becoming dilated and removing the heat
from the site.
C. We will increase the temperature 5 degrees when the pad no longer
feels warm.
D. The body's receptors adapt over time as they are exposed to heat.
,D. The body's receptors adapt over time as they are exposed to heat.
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat
application. (A and B) provide false information. (C) is not based on a
knowledge of physiology and is an unsafe action that may harm the client.
The nurse is instructing a client with high cholesterol about diet and
lifestyle modification. What comment from the client indicates that the
teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my
cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low-density lipoproteins needs to increase.
C. I will limit my intake of beef to 4 ounces per week.
Limiting saturated fat from animal food sources to no more than 4 ounces
per week (C) is an important diet modification for lowering cholesterol. To
be effective in reducing cholesterol, the client should exercise 30 minutes
per day, or at least 4 to 6 times per week (A). Red meat and all proteins do
not need to be eliminated (B) to lower cholesterol but should be restricted
to lean cuts of red meat and smaller portions (2-ounce servings). The low-
density lipoproteins (D) need to decrease rather than increase.
The UAPs working on a chronic neuro unit ask the nurse to help them
determine the safest way to transfer an elderly client with left-sided
weakness from the bed to the chair. What method describes the
correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side
,before moving.
B. Assist the client to a standing position, then place the right hand
on the armrest.
C. Have the client place the left foot next to the chair and pivot to the
left before sitting.
D. Move the chair parallel to the right side of the bed and stand the
client on the right foot.
D. Move the chair parallel to the right side of the bed and stand the client
on the right foot.
(D) uses the client's stronger side, the right side, for weight-bearing during
the transfer, and is the safest approach to take. (A, B, and C) are unsafe
methods of transfer and include the use of poor body mechanics by the
caregiver.
An unlicensed assistive personnel (UAP) places a client in a left
lateral position prior to administering a soap suds enema. Which
instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse
Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of
castile soap.
C. Reposition in a Sim's position with the client's weight on the
anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to
waist level.
C. Reposition in a Sim's position with the client's weight on the anterior
ilium.
, The left sided Sims' position allows the enema solution to follow the
anatomical course of the intestines and allows the best overall results, so
the UAP should reposition the client in the Sims' position, which distributes
the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D)
should be implemented once the client is positioned.
A client who is a Jehovah's Witness is admitted to the nursing unit.
Which concern should the nurse have for planning care in terms of
the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed.
B. Blood transfusions are forbidden.
Blood transfusions are forbidden (B) in the Jehovah's Witness religion.
Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of
these sects are vegetarian (D), but the direct impact on nursing care is (B).
The nurse observes that a male client has removed the covering from
an ice pack applied to his knee. What action should the nurse take
first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin.
A. Observe the appearance of the skin under the ice pack.
AND REVISED IN 2025-2026 DECEMBER
The nurse observes an unlicensed assistive personnel (UAP) taking a
client's blood pressure with a cuff that is too small, but the blood
pressure reading obtained is within the client's usual range. What
action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.
B. Reassess the client's blood pressure using a larger cuff.
The most important action is to ensure that an accurate BP reading is
obtained. The nurse should reassess the BP with the correct size cuff (B).
Reassessment should not be postponed (A). Though (C and D) are likely
indicated, these actions do not have the priority of (B).
Twenty minutes after beginning a heat application, the client states
that the heating pad no longer feels warm enough. What is the best
response by the nurse?
A. That means you have derived the maximum benefit, and the heat
can be removed.
B. Your blood vessels are becoming dilated and removing the heat
from the site.
C. We will increase the temperature 5 degrees when the pad no longer
feels warm.
D. The body's receptors adapt over time as they are exposed to heat.
,D. The body's receptors adapt over time as they are exposed to heat.
(D) describes thermal adaptation, which occurs 20 to 30 minutes after heat
application. (A and B) provide false information. (C) is not based on a
knowledge of physiology and is an unsafe action that may harm the client.
The nurse is instructing a client with high cholesterol about diet and
lifestyle modification. What comment from the client indicates that the
teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my
cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low-density lipoproteins needs to increase.
C. I will limit my intake of beef to 4 ounces per week.
Limiting saturated fat from animal food sources to no more than 4 ounces
per week (C) is an important diet modification for lowering cholesterol. To
be effective in reducing cholesterol, the client should exercise 30 minutes
per day, or at least 4 to 6 times per week (A). Red meat and all proteins do
not need to be eliminated (B) to lower cholesterol but should be restricted
to lean cuts of red meat and smaller portions (2-ounce servings). The low-
density lipoproteins (D) need to decrease rather than increase.
The UAPs working on a chronic neuro unit ask the nurse to help them
determine the safest way to transfer an elderly client with left-sided
weakness from the bed to the chair. What method describes the
correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side
,before moving.
B. Assist the client to a standing position, then place the right hand
on the armrest.
C. Have the client place the left foot next to the chair and pivot to the
left before sitting.
D. Move the chair parallel to the right side of the bed and stand the
client on the right foot.
D. Move the chair parallel to the right side of the bed and stand the client
on the right foot.
(D) uses the client's stronger side, the right side, for weight-bearing during
the transfer, and is the safest approach to take. (A, B, and C) are unsafe
methods of transfer and include the use of poor body mechanics by the
caregiver.
An unlicensed assistive personnel (UAP) places a client in a left
lateral position prior to administering a soap suds enema. Which
instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse
Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of
castile soap.
C. Reposition in a Sim's position with the client's weight on the
anterior ilium.
D. Raise the side rails on both sides of the bed and elevate the bed to
waist level.
C. Reposition in a Sim's position with the client's weight on the anterior
ilium.
, The left sided Sims' position allows the enema solution to follow the
anatomical course of the intestines and allows the best overall results, so
the UAP should reposition the client in the Sims' position, which distributes
the client's weight to the anterior ilium (C). (A) is inaccurate. (B and D)
should be implemented once the client is positioned.
A client who is a Jehovah's Witness is admitted to the nursing unit.
Which concern should the nurse have for planning care in terms of
the client's beliefs?
A. Autopsy of the body is prohibited.
B. Blood transfusions are forbidden.
C. Alcohol use in any form is not allowed.
D. A vegetarian diet must be followed.
B. Blood transfusions are forbidden.
Blood transfusions are forbidden (B) in the Jehovah's Witness religion.
Judaism prohibits (A). Buddhism forbids the use of (C) and drugs. Many of
these sects are vegetarian (D), but the direct impact on nursing care is (B).
The nurse observes that a male client has removed the covering from
an ice pack applied to his knee. What action should the nurse take
first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin.
A. Observe the appearance of the skin under the ice pack.
