ALL HESI FUNDAMENTALS EXAM TEST BANK UPDATED 2025 COMPREHENSIVE
QUESTIONS AND ANSWERS WITH RATIONALES
1. A nurse is caring for a client with a nasogastric (NG) tube for decompression.
Which action should the nurse take to confirm placement of the NG tube?
• A. Inject air into the tube and listen for a whooshing sound.
• B. Assess for the presence of gastric contents.
• C. Check the pH of the aspirated fluid.
• D. Measure the length of the exposed tube.
Answer: C. Check the pH of the aspirated fluid.
Rationale: Measuring the pH of gastric aspirate (normally ≤ 5) is a reliable way to
confirm NG tube placement. Injecting air and listening for a whooshing sound is
outdated and unreliable. Gastric content assessment and tube length
measurement can complement but not confirm placement.
2. A nurse is preparing to administer a blood transfusion. What is the first
priority action?
• A. Verify the client’s blood type with the transfusion record.
• B. Obtain baseline vital signs.
• C. Check for a signed consent form.
• D. Prime the blood tubing with normal saline.
Answer: C. Check for a signed consent form.
Rationale: Before any blood transfusion, informed consent must be verified.
Other actions are essential but occur after consent confirmation.
3. What is the primary goal of hand hygiene in a healthcare setting?
• A. To prevent hospital-acquired infections (HAIs).
, • B. To remove visible soil from hands.
• C. To reduce odors from hands.
• D. To meet facility policy requirements.
Answer: A. To prevent hospital-acquired infections (HAIs).
Rationale: Hand hygiene is the most effective method for preventing HAIs and
controlling the spread of pathogens.
4. A client is at risk for pressure injuries. Which intervention is most
appropriate?
• A. Massage reddened areas to increase circulation.
• B. Use a donut-shaped cushion under the sacrum.
• C. Reposition the client every 2 hours.
• D. Limit fluid intake to reduce skin moisture.
Answer: C. Reposition the client every 2 hours.
Rationale: Frequent repositioning helps relieve pressure and improve circulation.
Massaging reddened areas can cause tissue damage. Donut-shaped cushions
increase pressure and fluid restriction may lead to dehydration.
5. Which of the following clients is at the greatest risk for falls?
• A. A 45-year-old client with controlled hypertension.
• B. A 65-year-old client post-operative for cataract surgery.
• C. A 72-year-old client with orthostatic hypotension.
• D. A 29-year-old client with a sprained ankle.
Answer: C. A 72-year-old client with orthostatic hypotension.
Rationale: Orthostatic hypotension increases the risk of dizziness and falls,
particularly in older adults. The other clients have minimal risk factors.
, 6. Which task can the nurse safely delegate to an unlicensed assistive personnel
(UAP)?
• A. Administering oral medications.
• B. Performing a sterile dressing change.
• C. Assisting a client with bathing.
• D. Teaching a client about diabetes management.
Answer: C. Assisting a client with bathing.
Rationale: UAPs can perform non-invasive, routine tasks such as bathing.
Administering medications, sterile procedures, and client teaching require a
licensed nurse.
7. What is the correct method to remove PPE after caring for a client on contact
precautions?
• A. Gloves, gown, goggles, mask.
• B. Gown, gloves, mask, goggles.
• C. Mask, goggles, gown, gloves.
• D. Gloves, mask, gown, goggles.
Answer: A. Gloves, gown, goggles, mask.
Rationale: PPE should be removed in a sequence that prevents contamination,
starting with gloves and progressing to items less likely to be contaminated.
8. A nurse is documenting client care in the electronic health record (EHR).
Which action is most appropriate?
• A. Document only abnormal findings.
• B. Use vague terms to avoid legal liability.
• C. Document care after the end of the shift.
• D. Record care immediately after performing it.
QUESTIONS AND ANSWERS WITH RATIONALES
1. A nurse is caring for a client with a nasogastric (NG) tube for decompression.
Which action should the nurse take to confirm placement of the NG tube?
• A. Inject air into the tube and listen for a whooshing sound.
• B. Assess for the presence of gastric contents.
• C. Check the pH of the aspirated fluid.
• D. Measure the length of the exposed tube.
Answer: C. Check the pH of the aspirated fluid.
Rationale: Measuring the pH of gastric aspirate (normally ≤ 5) is a reliable way to
confirm NG tube placement. Injecting air and listening for a whooshing sound is
outdated and unreliable. Gastric content assessment and tube length
measurement can complement but not confirm placement.
2. A nurse is preparing to administer a blood transfusion. What is the first
priority action?
• A. Verify the client’s blood type with the transfusion record.
• B. Obtain baseline vital signs.
• C. Check for a signed consent form.
• D. Prime the blood tubing with normal saline.
Answer: C. Check for a signed consent form.
Rationale: Before any blood transfusion, informed consent must be verified.
Other actions are essential but occur after consent confirmation.
3. What is the primary goal of hand hygiene in a healthcare setting?
• A. To prevent hospital-acquired infections (HAIs).
, • B. To remove visible soil from hands.
• C. To reduce odors from hands.
• D. To meet facility policy requirements.
Answer: A. To prevent hospital-acquired infections (HAIs).
Rationale: Hand hygiene is the most effective method for preventing HAIs and
controlling the spread of pathogens.
4. A client is at risk for pressure injuries. Which intervention is most
appropriate?
• A. Massage reddened areas to increase circulation.
• B. Use a donut-shaped cushion under the sacrum.
• C. Reposition the client every 2 hours.
• D. Limit fluid intake to reduce skin moisture.
Answer: C. Reposition the client every 2 hours.
Rationale: Frequent repositioning helps relieve pressure and improve circulation.
Massaging reddened areas can cause tissue damage. Donut-shaped cushions
increase pressure and fluid restriction may lead to dehydration.
5. Which of the following clients is at the greatest risk for falls?
• A. A 45-year-old client with controlled hypertension.
• B. A 65-year-old client post-operative for cataract surgery.
• C. A 72-year-old client with orthostatic hypotension.
• D. A 29-year-old client with a sprained ankle.
Answer: C. A 72-year-old client with orthostatic hypotension.
Rationale: Orthostatic hypotension increases the risk of dizziness and falls,
particularly in older adults. The other clients have minimal risk factors.
, 6. Which task can the nurse safely delegate to an unlicensed assistive personnel
(UAP)?
• A. Administering oral medications.
• B. Performing a sterile dressing change.
• C. Assisting a client with bathing.
• D. Teaching a client about diabetes management.
Answer: C. Assisting a client with bathing.
Rationale: UAPs can perform non-invasive, routine tasks such as bathing.
Administering medications, sterile procedures, and client teaching require a
licensed nurse.
7. What is the correct method to remove PPE after caring for a client on contact
precautions?
• A. Gloves, gown, goggles, mask.
• B. Gown, gloves, mask, goggles.
• C. Mask, goggles, gown, gloves.
• D. Gloves, mask, gown, goggles.
Answer: A. Gloves, gown, goggles, mask.
Rationale: PPE should be removed in a sequence that prevents contamination,
starting with gloves and progressing to items less likely to be contaminated.
8. A nurse is documenting client care in the electronic health record (EHR).
Which action is most appropriate?
• A. Document only abnormal findings.
• B. Use vague terms to avoid legal liability.
• C. Document care after the end of the shift.
• D. Record care immediately after performing it.
