(Combined) HESI Fundamentals Practice Test,
Fundamentals HESI Exam,
Fundamentals/Foundations/H.A. HESI, Hesi
Fundamentals Practice Test, Nursing Fundamentals
HESI Prep, Updated 2024.
64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The
nurse determines that the client has been noncompliant with the diet, based on
which report from the 24-hour dietary recall? (Select all that apply.)
A. Snack of potato chips, and diet soda.
B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C. Breakfast of eggs, bacon, toast, and coffee.
D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E. Bedtime snack of crackers and milk.
Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers
(E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low
protein diet.
Correct Answer: A, B, C, E
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.
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.
,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.
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.
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.
,Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice
(B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to
relieve the client's constipation. (C) reduces discomfort during ambulation, but will not
help relieve the client's constipation. Defecation is not painful following most surgeries,
and many analgesics used postoperatively cause constipation, so (D) is
contraindicated.
Correct Answer: B
70.The home health nurse visits an elderly client who lives at home with her
husband. The client is experiencing frequent episodes of diarrhea and bowel
incontinence. Which problem, for which the client is at risk, has the greatest
priority when planning the client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance.
Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the
highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel
incontinence can also lead to (A, B, and C), but these are of less potential harm than a
fluid volume deficit.
Correct Answer: D
71.After a client has been premedicated for surgery with an opioid analgesic, the
nurse discovers that the operative permit has not been signed. What action
should the nurse implement?
A. Notify the surgeon that the consent form has not been signed.
B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature.
Once a client has been premedicated for surgery with any type of sedative, legal
informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and
D) are not legally viable options for ensuring informed consent.
Correct Answer: A
72.A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of bed for the
first time, the client becomes dizzy. What action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is
contacted.
D. Advise the client to sit on the side of the bed for a few minutes before standing
again.
The nurse should implement (D), because orthostatic hypotension is a common result of
immobilization, causing the client to feel dizzy when first getting out of bed following a
period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a
standing position by sitting upright for a short period (D) before rising to a standing
position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of
consciousness. (C) is not indicated and will increase the potential for complications
, associated with prolonged immobility.
Correct Answer: D
74.A client is admitted to the hospital with intractable pain. What instruction
should the nurse provide the unlicensed assistive personnel (UAP) who is
preparing to assist this client with a bed bath?
A. Take measures to promote as much comfort as possible.
B. Report any signs of drug addiction to the nurse immediately.
C. Wait until the client's pain is gone before assisting with personal care.
D. This client's pain will be difficult to manage, since the cause is unknown.
Intractable pain is highly resistant to pain relief measures, so it is important to promote
comfort (A) during all activities. A client with intractable pain may develop drug tolerance
and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant
to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation
that is perceived but has no known cause.
Correct Answer: A
75.A male client arrives at the outpatient surgery center for a scheduled needle
aspiration of the knee. He tells the nurse that he has already given verbal consent
for the procedure to the healthcare provider. What action should the nurse
implement?
A. Witness the client's signature on the consent form.
B. Verify the client's consent with the healthcare provider.
C. Notify the healthcare provider that the client is ready for the procedure.
D. Document that the client has given consent for the needle aspiration.
Written informed consent is required prior to any invasive procedure. The healthcare
provider must explain the procedure to the client, but the nurse can witness the client's
signature on a consent form (A). (B) is not necessary since written consent must be
obtained. (C) is not correct because written consent has not been obtained. (D) must
occur after written consent is obtained.
Correct Answer: A
76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel
the pulsation while the client is in a supine position. What action should the
nurse implement?
A. Elevate the head of the bed and attempt to palpate the site again.
B. Document the presence and volume of the pulse palpated.
C. Use a thigh cuff to measure the blood pressure in the leg.
D. Record the presence of pitting edema in the inguinal area.
Deep palpation may be required to palpate the femoral pulse; and, when palpated, the
nurse should document the presence and volume of the pulse (B). The site is best
palpated with the client supine; elevation of the head of the bed requires even deeper
palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a
problem requiring further assessment, such as (C), and does not reflect the presence of
edema (D).
Correct Answer: B
77.A nurse is preparing to insert a rectal suppository and observes a small
amount of rectal bleeding. What action should the nurse implement?
A. Administer the medication as scheduled after assessing the client's vital signs.
Fundamentals HESI Exam,
Fundamentals/Foundations/H.A. HESI, Hesi
Fundamentals Practice Test, Nursing Fundamentals
HESI Prep, Updated 2024.
64.A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The
nurse determines that the client has been noncompliant with the diet, based on
which report from the 24-hour dietary recall? (Select all that apply.)
A. Snack of potato chips, and diet soda.
B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C. Breakfast of eggs, bacon, toast, and coffee.
D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E. Bedtime snack of crackers and milk.
Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers
(E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low
protein diet.
Correct Answer: A, B, C, E
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.
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.
,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.
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.
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.
,Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice
(B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to
relieve the client's constipation. (C) reduces discomfort during ambulation, but will not
help relieve the client's constipation. Defecation is not painful following most surgeries,
and many analgesics used postoperatively cause constipation, so (D) is
contraindicated.
Correct Answer: B
70.The home health nurse visits an elderly client who lives at home with her
husband. The client is experiencing frequent episodes of diarrhea and bowel
incontinence. Which problem, for which the client is at risk, has the greatest
priority when planning the client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance.
Diarrhea can lead to fluid volume loss, which is potentially life-threatening, so the
highest priority is to prevent a fluid volume imbalance (D). Diarrhea and bowel
incontinence can also lead to (A, B, and C), but these are of less potential harm than a
fluid volume deficit.
Correct Answer: D
71.After a client has been premedicated for surgery with an opioid analgesic, the
nurse discovers that the operative permit has not been signed. What action
should the nurse implement?
A. Notify the surgeon that the consent form has not been signed.
B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature.
Once a client has been premedicated for surgery with any type of sedative, legal
informed consent is not possible, so the nurse must notify the surgeon (A). (B, C, and
D) are not legally viable options for ensuring informed consent.
Correct Answer: A
72.A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of bed for the
first time, the client becomes dizzy. What action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is
contacted.
D. Advise the client to sit on the side of the bed for a few minutes before standing
again.
The nurse should implement (D), because orthostatic hypotension is a common result of
immobilization, causing the client to feel dizzy when first getting out of bed following a
period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a
standing position by sitting upright for a short period (D) before rising to a standing
position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of
consciousness. (C) is not indicated and will increase the potential for complications
, associated with prolonged immobility.
Correct Answer: D
74.A client is admitted to the hospital with intractable pain. What instruction
should the nurse provide the unlicensed assistive personnel (UAP) who is
preparing to assist this client with a bed bath?
A. Take measures to promote as much comfort as possible.
B. Report any signs of drug addiction to the nurse immediately.
C. Wait until the client's pain is gone before assisting with personal care.
D. This client's pain will be difficult to manage, since the cause is unknown.
Intractable pain is highly resistant to pain relief measures, so it is important to promote
comfort (A) during all activities. A client with intractable pain may develop drug tolerance
and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant
to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation
that is perceived but has no known cause.
Correct Answer: A
75.A male client arrives at the outpatient surgery center for a scheduled needle
aspiration of the knee. He tells the nurse that he has already given verbal consent
for the procedure to the healthcare provider. What action should the nurse
implement?
A. Witness the client's signature on the consent form.
B. Verify the client's consent with the healthcare provider.
C. Notify the healthcare provider that the client is ready for the procedure.
D. Document that the client has given consent for the needle aspiration.
Written informed consent is required prior to any invasive procedure. The healthcare
provider must explain the procedure to the client, but the nurse can witness the client's
signature on a consent form (A). (B) is not necessary since written consent must be
obtained. (C) is not correct because written consent has not been obtained. (D) must
occur after written consent is obtained.
Correct Answer: A
76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel
the pulsation while the client is in a supine position. What action should the
nurse implement?
A. Elevate the head of the bed and attempt to palpate the site again.
B. Document the presence and volume of the pulse palpated.
C. Use a thigh cuff to measure the blood pressure in the leg.
D. Record the presence of pitting edema in the inguinal area.
Deep palpation may be required to palpate the femoral pulse; and, when palpated, the
nurse should document the presence and volume of the pulse (B). The site is best
palpated with the client supine; elevation of the head of the bed requires even deeper
palpation (A). The use of deep palpation to feel the femoral pulse does not indicate a
problem requiring further assessment, such as (C), and does not reflect the presence of
edema (D).
Correct Answer: B
77.A nurse is preparing to insert a rectal suppository and observes a small
amount of rectal bleeding. What action should the nurse implement?
A. Administer the medication as scheduled after assessing the client's vital signs.
