HESI Fundamentals Herzing University -Hesi
Fundamentals Exam Fall 2025
Course
HESI Fundamentals
1. Which of the following is an example of a nursing intervention to prevent a
pressure ulcer?
A) Reposition the patient every 2 hours.
B) Administer pain medication every 6 hours.
C) Perform a complete physical assessment once a week.
D) Limit the patient’s fluid intake.
✅ Correct Answer: A) Reposition the patient every 2 hours.
Rationale:
Repositioning patients at regular intervals, typically every 2 hours, helps relieve pressure on
bony prominences and prevents the formation of pressure ulcers. Pain medication and physical
assessments, while important, are not specifically aimed at preventing pressure ulcers. Limiting
fluid intake can increase the risk of dehydration, which is a factor in skin breakdown.
2. What is the priority action for a nurse when a patient is found unresponsive
and not breathing?
A) Start chest compressions.
B) Assess the patient’s blood pressure.
C) Check the patient's pulse.
D) Administer oxygen via nasal cannula.
✅ Correct Answer: A) Start chest compressions.
Rationale:
In a patient who is unresponsive and not breathing, the priority action is to initiate chest
compressions to provide circulation to vital organs, especially the brain. Checking the pulse is
important but should not delay the start of compressions in a non-breathing patient.
Administering oxygen should be done after circulation is established.
3. Which of the following would be most appropriate to include in the care plan
for a patient with a history of falls?
,A) Place a fall risk bracelet on the patient’s wrist.
B) Keep the patient’s bed in a high position to prevent injury.
C) Encourage the patient to walk unassisted for exercise.
D) Place a wet cloth on the patient’s forehead.
✅ Correct Answer: A) Place a fall risk bracelet on the patient’s wrist.
Rationale:
A fall risk bracelet alerts the healthcare team to the patient’s increased risk of falling. Keeping
the bed in a high position increases the risk of falls. Encouraging walking unassisted without
proper assessment of the patient's mobility is unsafe. A wet cloth on the forehead may be helpful
for comfort but is unrelated to fall prevention.
4. The nurse is caring for a patient who has just undergone a left-sided
mastectomy. Which statement by the patient indicates the need for further
teaching about the care of the affected arm?
A) “I will avoid lifting heavy objects with my left arm.”
B) “I will apply lotion to my left arm daily to keep the skin soft.”
C) “I will wear a compression sleeve on my left arm if I develop swelling.”
D) “I will take hot showers to relax my muscles on the left side.”
✅ Correct Answer: D) “I will take hot showers to relax my muscles on the left side.”
Rationale:
After a mastectomy, patients are at risk for lymphedema and should avoid activities that could
stress the affected arm, such as hot showers, which can lead to increased swelling. The other
options are appropriate for the care of the affected arm.
5. What is the most important consideration when providing care for a patient
who is receiving a blood transfusion?
A) Administer the transfusion at a rapid rate.
B) Use a blood warmer for all transfusions.
C) Monitor the patient for signs of a transfusion reaction.
D) Obtain a blood sample before the transfusion for crossmatch.
✅ Correct Answer: C) Monitor the patient for signs of a transfusion reaction.
Rationale:
The priority during a blood transfusion is to monitor the patient closely for signs of a transfusion
,reaction, such as fever, chills, rash, or difficulty breathing. The transfusion should not be given
rapidly unless specified in the care plan, and blood warmers are used only for specific situations.
A crossmatch should be done before the transfusion, but monitoring for reactions is more
immediate.
6. Which of the following actions by the nurse is most appropriate when
performing a sterile dressing change?
A) Wear sterile gloves and maintain a sterile field.
B) Open the dressing package before washing hands.
C) Clean the wound with sterile water only.
D) Dispose of all items in a regular trash can.
✅ Correct Answer: A) Wear sterile gloves and maintain a sterile field.
Rationale:
To ensure the dressing change is done safely and without introducing infection, sterile gloves
must be worn, and a sterile field must be maintained. Hands should be washed before opening
sterile packages, and the wound should be cleaned with the appropriate solution, which could
include sterile saline, not just sterile water. Disposed items should be placed in a biohazard
container, not a regular trash can.
7. The nurse is assessing a patient’s vital signs. Which of the following findings is
most concerning and requires immediate intervention?
A) Blood pressure 120/80 mmHg
B) Heart rate 110 bpm
C) Respiratory rate 16 breaths per minute
D) Temperature 101.5°F (38.6°C)
✅ Correct Answer: B) Heart rate 110 bpm
Rationale:
A heart rate of 110 bpm is tachycardia and may indicate underlying issues such as infection,
anemia, or hypovolemia. It requires immediate attention to assess the cause. The other findings,
while noteworthy, are within normal ranges or acceptable limits.
8. A patient has just received an opioid pain medication. What is the most
important assessment the nurse should perform?
, A) Check the patient’s blood pressure.
B) Monitor the patient's respiratory rate.
C) Assess the patient’s body temperature.
D) Measure the patient’s blood glucose level.
✅ Correct Answer: B) Monitor the patient's respiratory rate.
Rationale:
Opioids can cause respiratory depression, so it is critical to monitor the patient's respiratory rate
to detect any signs of decreased breathing. Blood pressure and temperature may be important,
but respiratory assessment is the most urgent.
9. Which of the following interventions is the priority when a patient is
experiencing a seizure?
A) Insert an oral airway to prevent the patient from biting their tongue.
B) Place the patient in a lateral position.
C) Administer oxygen via nasal cannula.
D) Restrain the patient to prevent injury.
✅ Correct Answer: B) Place the patient in a lateral position.
Rationale:
Placing the patient in a lateral (side-lying) position helps to prevent aspiration and keeps the
airway clear. Restraining the patient could cause injury, and inserting an oral airway is not
recommended unless directed by a healthcare provider. Administering oxygen can be done if
necessary, but airway positioning takes priority.
10. A nurse is educating a patient about taking their prescribed antihypertensive
medication. Which statement by the patient indicates a need for further
education?
A) “I will take my medication at the same time every day.”
B) “I should avoid standing up quickly to prevent dizziness.”
C) “It’s okay to stop the medication once my blood pressure is normal.”
D) “I will notify my healthcare provider if I experience any side effects.”
✅ Correct Answer: C) “It’s okay to stop the medication once my blood pressure is normal.”
Rationale:
Patients should not stop taking antihypertensive medications without consulting their healthcare
Fundamentals Exam Fall 2025
Course
HESI Fundamentals
1. Which of the following is an example of a nursing intervention to prevent a
pressure ulcer?
A) Reposition the patient every 2 hours.
B) Administer pain medication every 6 hours.
C) Perform a complete physical assessment once a week.
D) Limit the patient’s fluid intake.
✅ Correct Answer: A) Reposition the patient every 2 hours.
Rationale:
Repositioning patients at regular intervals, typically every 2 hours, helps relieve pressure on
bony prominences and prevents the formation of pressure ulcers. Pain medication and physical
assessments, while important, are not specifically aimed at preventing pressure ulcers. Limiting
fluid intake can increase the risk of dehydration, which is a factor in skin breakdown.
2. What is the priority action for a nurse when a patient is found unresponsive
and not breathing?
A) Start chest compressions.
B) Assess the patient’s blood pressure.
C) Check the patient's pulse.
D) Administer oxygen via nasal cannula.
✅ Correct Answer: A) Start chest compressions.
Rationale:
In a patient who is unresponsive and not breathing, the priority action is to initiate chest
compressions to provide circulation to vital organs, especially the brain. Checking the pulse is
important but should not delay the start of compressions in a non-breathing patient.
Administering oxygen should be done after circulation is established.
3. Which of the following would be most appropriate to include in the care plan
for a patient with a history of falls?
,A) Place a fall risk bracelet on the patient’s wrist.
B) Keep the patient’s bed in a high position to prevent injury.
C) Encourage the patient to walk unassisted for exercise.
D) Place a wet cloth on the patient’s forehead.
✅ Correct Answer: A) Place a fall risk bracelet on the patient’s wrist.
Rationale:
A fall risk bracelet alerts the healthcare team to the patient’s increased risk of falling. Keeping
the bed in a high position increases the risk of falls. Encouraging walking unassisted without
proper assessment of the patient's mobility is unsafe. A wet cloth on the forehead may be helpful
for comfort but is unrelated to fall prevention.
4. The nurse is caring for a patient who has just undergone a left-sided
mastectomy. Which statement by the patient indicates the need for further
teaching about the care of the affected arm?
A) “I will avoid lifting heavy objects with my left arm.”
B) “I will apply lotion to my left arm daily to keep the skin soft.”
C) “I will wear a compression sleeve on my left arm if I develop swelling.”
D) “I will take hot showers to relax my muscles on the left side.”
✅ Correct Answer: D) “I will take hot showers to relax my muscles on the left side.”
Rationale:
After a mastectomy, patients are at risk for lymphedema and should avoid activities that could
stress the affected arm, such as hot showers, which can lead to increased swelling. The other
options are appropriate for the care of the affected arm.
5. What is the most important consideration when providing care for a patient
who is receiving a blood transfusion?
A) Administer the transfusion at a rapid rate.
B) Use a blood warmer for all transfusions.
C) Monitor the patient for signs of a transfusion reaction.
D) Obtain a blood sample before the transfusion for crossmatch.
✅ Correct Answer: C) Monitor the patient for signs of a transfusion reaction.
Rationale:
The priority during a blood transfusion is to monitor the patient closely for signs of a transfusion
,reaction, such as fever, chills, rash, or difficulty breathing. The transfusion should not be given
rapidly unless specified in the care plan, and blood warmers are used only for specific situations.
A crossmatch should be done before the transfusion, but monitoring for reactions is more
immediate.
6. Which of the following actions by the nurse is most appropriate when
performing a sterile dressing change?
A) Wear sterile gloves and maintain a sterile field.
B) Open the dressing package before washing hands.
C) Clean the wound with sterile water only.
D) Dispose of all items in a regular trash can.
✅ Correct Answer: A) Wear sterile gloves and maintain a sterile field.
Rationale:
To ensure the dressing change is done safely and without introducing infection, sterile gloves
must be worn, and a sterile field must be maintained. Hands should be washed before opening
sterile packages, and the wound should be cleaned with the appropriate solution, which could
include sterile saline, not just sterile water. Disposed items should be placed in a biohazard
container, not a regular trash can.
7. The nurse is assessing a patient’s vital signs. Which of the following findings is
most concerning and requires immediate intervention?
A) Blood pressure 120/80 mmHg
B) Heart rate 110 bpm
C) Respiratory rate 16 breaths per minute
D) Temperature 101.5°F (38.6°C)
✅ Correct Answer: B) Heart rate 110 bpm
Rationale:
A heart rate of 110 bpm is tachycardia and may indicate underlying issues such as infection,
anemia, or hypovolemia. It requires immediate attention to assess the cause. The other findings,
while noteworthy, are within normal ranges or acceptable limits.
8. A patient has just received an opioid pain medication. What is the most
important assessment the nurse should perform?
, A) Check the patient’s blood pressure.
B) Monitor the patient's respiratory rate.
C) Assess the patient’s body temperature.
D) Measure the patient’s blood glucose level.
✅ Correct Answer: B) Monitor the patient's respiratory rate.
Rationale:
Opioids can cause respiratory depression, so it is critical to monitor the patient's respiratory rate
to detect any signs of decreased breathing. Blood pressure and temperature may be important,
but respiratory assessment is the most urgent.
9. Which of the following interventions is the priority when a patient is
experiencing a seizure?
A) Insert an oral airway to prevent the patient from biting their tongue.
B) Place the patient in a lateral position.
C) Administer oxygen via nasal cannula.
D) Restrain the patient to prevent injury.
✅ Correct Answer: B) Place the patient in a lateral position.
Rationale:
Placing the patient in a lateral (side-lying) position helps to prevent aspiration and keeps the
airway clear. Restraining the patient could cause injury, and inserting an oral airway is not
recommended unless directed by a healthcare provider. Administering oxygen can be done if
necessary, but airway positioning takes priority.
10. A nurse is educating a patient about taking their prescribed antihypertensive
medication. Which statement by the patient indicates a need for further
education?
A) “I will take my medication at the same time every day.”
B) “I should avoid standing up quickly to prevent dizziness.”
C) “It’s okay to stop the medication once my blood pressure is normal.”
D) “I will notify my healthcare provider if I experience any side effects.”
✅ Correct Answer: C) “It’s okay to stop the medication once my blood pressure is normal.”
Rationale:
Patients should not stop taking antihypertensive medications without consulting their healthcare
