HESI FUNDAMENTALS PRACTICE
EXAM QUESTIONS WITH ANSWERS –
100% CORRECT
During the daily nursing assessment, a client begins to cry and states that the
majority of family and friends have stopped calling and visiting. What action
should the nurse take?
A. Listen and show interest as the client expresses these feelings.
B. Reinforce that this behavior means they were not true friends.
C. Ask the HCP for psychiatric consult.
D. Continue with the assessment and tell the client not to worry.
- CORRECT ANSWER- A. Listen and show interest as the client expresses these
feelings.
(When a client begins to cry and express feelings, a therapeutic nursing intervention is
to listen and show interest as the client expresses feelings (A). (B) is not a therapeutic
option and the nurse does not know the dynamics of their relationships. (C) is not
indicated at this time. (D) is non-therapeutic and offers false hope.)
The nurse plans to obtain health assessment information from a primary source.
Which option is a primary source for the completion of the health assessment?
- CORRECT ANSWER- CLIENT (HCP, fam, previous medical records-- secondary
sources)
The nurse observes that a male client has removed the covering from an ice park
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.
- CORRECT ANSWER- Observe the appearance of the skin under the ice pack (The
first action taken by the nurse should be to assess the skin for any possible thermal
injury. If no injury to the skin has occurred, the nurse can take the other actions.)
,The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor
of 60 gtt/mL, how many drops per minute should the client receive?
- CORRECT ANSWER- 124 gtt/min
The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate
w/ 30 units of Pitocin to run in over 4 hours for a client who has just delivered a
10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml
administration set. The nurse plans to set the flow rate at how many gtt/min?
- CORRECT ANSWER- 83 gtt/min
Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube?
- CORRECT ANSWER- Examining a chest x-ray obtained after the tubing was
inserted
Three days following a surgery, a male client observes his colostomy for the first
time. He becomes quite upset and tells the nurse that it is much bigger than he
expected. What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in
time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure.
- CORRECT ANSWER- B. Instruct the client that the stoma will become smaller
when the initial swelling diminishes
(Postoperative swelling causes enlargement of the stoma. The nurse can teach the
client that the stoma will become smaller when swelling is diminished (B). This will help
reduce the client's anxiety and promote acceptance of the colostomy. (A) does not
provide helpful teaching or support. (C) is a useful action, and may be taken after the
nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn
colostomy care. (D)
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last two hours. What action should the nurse take first?
, A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.
- CORRECT ANSWER- B. Reposition the client on her side.
(The immediate priority is to determine if the tube is functioning correctly, which would
then relieve the client's nausea. The least invasive intervention (B) should be attempted
first, followed by (A and C), unless either of these interventions is contraindicated. If
these measures are unsuccessful, the client may require an antiemetic (D))
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. What action is best for
the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
- CORRECT ANSWER- C. After clearing the tube with 30 ml of air, check the pH of
fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time
- CORRECT ANSWER- D. is disoriented to place and time
(The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The
client is able to express himself without difficulty (B), and does not demonstrate
diminished attention span. (C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his
breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
EXAM QUESTIONS WITH ANSWERS –
100% CORRECT
During the daily nursing assessment, a client begins to cry and states that the
majority of family and friends have stopped calling and visiting. What action
should the nurse take?
A. Listen and show interest as the client expresses these feelings.
B. Reinforce that this behavior means they were not true friends.
C. Ask the HCP for psychiatric consult.
D. Continue with the assessment and tell the client not to worry.
- CORRECT ANSWER- A. Listen and show interest as the client expresses these
feelings.
(When a client begins to cry and express feelings, a therapeutic nursing intervention is
to listen and show interest as the client expresses feelings (A). (B) is not a therapeutic
option and the nurse does not know the dynamics of their relationships. (C) is not
indicated at this time. (D) is non-therapeutic and offers false hope.)
The nurse plans to obtain health assessment information from a primary source.
Which option is a primary source for the completion of the health assessment?
- CORRECT ANSWER- CLIENT (HCP, fam, previous medical records-- secondary
sources)
The nurse observes that a male client has removed the covering from an ice park
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.
- CORRECT ANSWER- Observe the appearance of the skin under the ice pack (The
first action taken by the nurse should be to assess the skin for any possible thermal
injury. If no injury to the skin has occurred, the nurse can take the other actions.)
,The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor
of 60 gtt/mL, how many drops per minute should the client receive?
- CORRECT ANSWER- 124 gtt/min
The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate
w/ 30 units of Pitocin to run in over 4 hours for a client who has just delivered a
10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml
administration set. The nurse plans to set the flow rate at how many gtt/min?
- CORRECT ANSWER- 83 gtt/min
Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube?
- CORRECT ANSWER- Examining a chest x-ray obtained after the tubing was
inserted
Three days following a surgery, a male client observes his colostomy for the first
time. He becomes quite upset and tells the nurse that it is much bigger than he
expected. What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance in
time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure.
- CORRECT ANSWER- B. Instruct the client that the stoma will become smaller
when the initial swelling diminishes
(Postoperative swelling causes enlargement of the stoma. The nurse can teach the
client that the stoma will become smaller when swelling is diminished (B). This will help
reduce the client's anxiety and promote acceptance of the colostomy. (A) does not
provide helpful teaching or support. (C) is a useful action, and may be taken after the
nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn
colostomy care. (D)
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last two hours. What action should the nurse take first?
, A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.
- CORRECT ANSWER- B. Reposition the client on her side.
(The immediate priority is to determine if the tube is functioning correctly, which would
then relieve the client's nausea. The least invasive intervention (B) should be attempted
first, followed by (A and C), unless either of these interventions is contraindicated. If
these measures are unsuccessful, the client may require an antiemetic (D))
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. What action is best for
the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
- CORRECT ANSWER- C. After clearing the tube with 30 ml of air, check the pH of
fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time
- CORRECT ANSWER- D. is disoriented to place and time
(The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The
client is able to express himself without difficulty (B), and does not demonstrate
diminished attention span. (C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his
breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
