HESI RN FUNDAMENTALS EXAM QUESTIONS WITH
ANSWERS AND RATIONALES 2023 UPDATED COMPLETE A+
GUIDE.
HESI RN FUNDAMENTALS
• A 20-year-old female client with a noticeable body odor has refused to shower for
thelast 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
• Accept and document the client's wish to refrain from bathing.
• Offer to give the client a bed bath, avoiding the perineal area.
• Obtain written brochures about menstruation to give to the client.
• 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-
mobilehas redness in the sacral area. Which instruction is most important for the
nurse to provide?
• Take a vitamin supplement tablet once a day.
• Change positions in the chair at least every hour.
• Increase daily intake of water or other oral fluids.
• 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.
,• After a needle stick occurs while removing the cap from a sterile needle,
whichaction should the nurse implement?
• Complete an incident report.
• Select another sterile needle.
• Disinfect the needle with an alcohol swab.
• Notify the supervisor of the department immediately.: B
Rationale: After a needle stick, the needle is considered used, so the nurse should discard it
and select another needle. Because the needle was sterile when the nurse was stuck and the
needle was not in contact with any other person's body fluids, the nurse does not need to
complete an incident report or notify the occupational health nurse. Disinfecting a needle
with an alcohol swab is not in accordance with standards for safe practice and infection
control.
• After receiving written and verbal instructions from a clinic nurse about a
newly prescribed medication, a client asks the nurse what to do if questions arise
about themedication after getting home. How should the nurse respond?
• Provide the client with a list of Internet sites that answer frequently
askedquestions about medications.
• Advise the client to obtain a current edition of a drug reference book
from alocal bookstore or library.
• Reassure the client that information about the medication is included in
thewritten instructions.
• Encourage the client to call the clinic nurse or health care provider if
anyquestions arise.: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the
nurse or health care provider if any questions arise. Options A, B, and C may all include
,usefulinformation, but these sources of information cannot evaluate the nature of the
client's questions and the follow-up needed.
• After the nurse tells an older client that an IV line needs to be inserted, the client
becomes very apprehensive, loudly verbalizing a dislike for all health care providers
andnurses. How should the nurse respond?
• Ask the client to remain quiet so the procedure can be performed safely.
• Concentrate on completing the insertion as efficiently as possible.
• Calmly reassure the client that the discomfort will be temporary.
• Tell the client a joke as a means of distraction from the procedure.: C
Rationale: The nurse should respond with a calm demeanor to help reduce the
client's apprehension. After responding calmly to the client's apprehension, the
nurse may implement toensure safe completion of the procedure.
• Based on the nursing diagnosis of risk for infection, which intervention is best for
thenurse to implement when providing care for an older incontinent client?
• Maintain standard precautions.
• Initiate contact isolation measures.
• Insert an indwelling urinary catheter.
• Instruct client in the use of adult diapers.: A
Rationale: The best action to decrease the risk of infection in vulnerable clients is
handwashing.Option B is not necessary unless the client has an infection. Option C increases
the risk of infection. Option D does not reduce the risk of infection.
• By rolling contaminated gloves inside-out, the nurse is affecting which step in the
chainof infection?
• Mode of transmission
• Portal of entry
, • C.Reservoir
• D.Portal of exit: A
Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit
ofthe reservoir to a portal of entry.
• A client becomes angry while waiting for a supervised break to smoke a cigarette
outsideand 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?
• Encourage the client to use a nicotine patch.
• Reassure the client that it is almost time for another break.
• Have the client leave the unit with another staff member.
• Review the schedule of outdoor breaks with the client.: D
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 dofirst?
• Clamp the nasogastric tube.
• Confirm placement of the tube.
• Use a syringe to instill the medications.
• Turn off the intermittent suction device.: D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube
inthe stomach before instilling the medications. To prevent immediate removal of the
ANSWERS AND RATIONALES 2023 UPDATED COMPLETE A+
GUIDE.
HESI RN FUNDAMENTALS
• A 20-year-old female client with a noticeable body odor has refused to shower for
thelast 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
• Accept and document the client's wish to refrain from bathing.
• Offer to give the client a bed bath, avoiding the perineal area.
• Obtain written brochures about menstruation to give to the client.
• 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-
mobilehas redness in the sacral area. Which instruction is most important for the
nurse to provide?
• Take a vitamin supplement tablet once a day.
• Change positions in the chair at least every hour.
• Increase daily intake of water or other oral fluids.
• 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.
,• After a needle stick occurs while removing the cap from a sterile needle,
whichaction should the nurse implement?
• Complete an incident report.
• Select another sterile needle.
• Disinfect the needle with an alcohol swab.
• Notify the supervisor of the department immediately.: B
Rationale: After a needle stick, the needle is considered used, so the nurse should discard it
and select another needle. Because the needle was sterile when the nurse was stuck and the
needle was not in contact with any other person's body fluids, the nurse does not need to
complete an incident report or notify the occupational health nurse. Disinfecting a needle
with an alcohol swab is not in accordance with standards for safe practice and infection
control.
• After receiving written and verbal instructions from a clinic nurse about a
newly prescribed medication, a client asks the nurse what to do if questions arise
about themedication after getting home. How should the nurse respond?
• Provide the client with a list of Internet sites that answer frequently
askedquestions about medications.
• Advise the client to obtain a current edition of a drug reference book
from alocal bookstore or library.
• Reassure the client that information about the medication is included in
thewritten instructions.
• Encourage the client to call the clinic nurse or health care provider if
anyquestions arise.: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the
nurse or health care provider if any questions arise. Options A, B, and C may all include
,usefulinformation, but these sources of information cannot evaluate the nature of the
client's questions and the follow-up needed.
• After the nurse tells an older client that an IV line needs to be inserted, the client
becomes very apprehensive, loudly verbalizing a dislike for all health care providers
andnurses. How should the nurse respond?
• Ask the client to remain quiet so the procedure can be performed safely.
• Concentrate on completing the insertion as efficiently as possible.
• Calmly reassure the client that the discomfort will be temporary.
• Tell the client a joke as a means of distraction from the procedure.: C
Rationale: The nurse should respond with a calm demeanor to help reduce the
client's apprehension. After responding calmly to the client's apprehension, the
nurse may implement toensure safe completion of the procedure.
• Based on the nursing diagnosis of risk for infection, which intervention is best for
thenurse to implement when providing care for an older incontinent client?
• Maintain standard precautions.
• Initiate contact isolation measures.
• Insert an indwelling urinary catheter.
• Instruct client in the use of adult diapers.: A
Rationale: The best action to decrease the risk of infection in vulnerable clients is
handwashing.Option B is not necessary unless the client has an infection. Option C increases
the risk of infection. Option D does not reduce the risk of infection.
• By rolling contaminated gloves inside-out, the nurse is affecting which step in the
chainof infection?
• Mode of transmission
• Portal of entry
, • C.Reservoir
• D.Portal of exit: A
Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit
ofthe reservoir to a portal of entry.
• A client becomes angry while waiting for a supervised break to smoke a cigarette
outsideand 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?
• Encourage the client to use a nicotine patch.
• Reassure the client that it is almost time for another break.
• Have the client leave the unit with another staff member.
• Review the schedule of outdoor breaks with the client.: D
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 dofirst?
• Clamp the nasogastric tube.
• Confirm placement of the tube.
• Use a syringe to instill the medications.
• Turn off the intermittent suction device.: D
Rationale: The nurse should first turn off the suction and then confirm placement of the tube
inthe stomach before instilling the medications. To prevent immediate removal of the
