Comprehensive Hesi Fundamentals Test 2025
Comprehensive Hesi Fundamentals Test 2025
,Comprehensive Hesi Fundamentals Test 2025
1. The home health nurse visits an elderly female client who had a brain
attack three months ago and is now able to ambulate with the assistance of
a quad cane. Which assessment finding has the greatest implications for
this client's care?
• The husband, who is the caregiver, begins to weep when the nurse asks how he is
doing.
• The client tells the nurse that she does not have much of an appetite today.
• The nurse notes that there are numerous scatter rugs throughout the
house.Correct
• The client's pulse rate is 10 beats higher than it was at the last visit one
week ago. Scatter rugs (C) pose a safety hazard because the client can trip on
them when ambulating, so this finding has the greatest significance in
planning this client's care.Psychological support of the caregiver (A) is a less
acute need than that of client safety. The nurse needs to obtain more
information about (B), but this is not a safety issue. (D) is not a significant
increase, and additional assessment might provide information about the
reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a client. The nurse
should stop the procedure and take corrective action if which client reaction
is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the
anal sphincter, which should be stopped if the client experiences a vagal
response, such asbrady cardia (B). (A, C, and D) do not warrant stopping
the procedure.
3. The nurse is providing passive range of motion (ROM) exercises to the hip
and knee for a client who is unconscious. After supporting the client's knee
with one hand,what action should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct
Passive ROM exercise for the hip and knee is provided by supporting the
joints of the knee and ankle (D) and gently moving the limb in a slow,
smooth, firm but gentle manner. (A) should be done before the exercises are
begun to prevent injury to the nurse and client. (B) is carried out after both
,Comprehensive Hesi Fundamentals Test 2025
joints are supported. After the knee is bent, then the knee is moved toward the chest
to the point of resistance
(C) two or three times.
4. A client who has moderate, persistent, chronic neuropathic pain due to
diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin,
Advil) daily. If Step2 of the World Health Organization (WHO) pain relief
ladder is prescribed, which drug protocol should be implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin (Neurontin), an antiseizure medication, may be used at any step
for anxiety and pain management, so (A) should be implemented. Nonopiod
analgesics, such as ibuprofen
(A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics
(D), and to maintain freedom from pain, drugs should be given around the
clock rather than by the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling urinary catheter
using an open technique. What action should the nurse take after
applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe. Correct
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution.
To irrigate an indwelling urinary catheter, the nurse should first apply gloves,
then draw up the irrigating solution into the syringe (B). The syringe is then
attached to the catheter and the fluid instilled, using aseptic technique (D).
Once the irrigating solution is instilled, the client's catheter should be secured
to the drainage tubing (C). The urinary drainage bag can be emptied (A)
whenever intake and output measurement is indicated, and the instilled
irrigating fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier gloves as
required by the protocol for Standard Precautions?
• Removing the empty food tray from a client with a urinary catheter.
• Washing and combing the hair of a client with a fractured leg in traction.
• Administering oral medications to a cooperative client with a wound infection.
• Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease. Correct
, Comprehensive Hesi Fundamentals Test 2025
Possible contact with body secretions, excretions, or broken skin is an
indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage
bag requires the use of gloves (D). (A, B, and C) do not require gloves.
7. What action should the nurse implement to prevent the formation of a
sacral ulcer for a client who is immobile?
• Maintain in a lateral position using protective wrist and vest devices.
• Position prone with a small pillow below the diaphragm. Correct
• Raise the head and knee gatch when lying in a supine position.
• Transfer into a wheelchair close to the nurse's station for observation.
The prone position (B) using a small pillow below the diaphragm maintains
alignment and provides the best pressure relief over the sacral bony
prominence. Using protective (restraining) devices (A) is not indicated.
Raising the head and bed gatch
(C) may reduce shearing forces due to sliding down in bed, but it interferes
with venous return from the legs and places pressure on the sacrum,
predisposing to ulcer formation. Sitting in a wheelchair (D) places the body
weight over the ischial tuber osities and predisposes to a potential pressure
point.
8. 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?
• Check capillary refill of toes on lower extremity with Unna's paste
boot.Correct
• Apply dressing to wound area before applying the Unna's paste boot.
• Wrap the leg from the knee down towards the foot.
• 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 removedq8h. Weekly removal is
reasonable (D).
9. The nurse is administering an intermittent infusion of an antibiotic to a
client whose intravenous (IV) access is an antecubital saline lock. After
the nurse opens the roller clamp on the IV tubing, the alarm on the
infusion pump indicates an obstruction. What action should the nurse
take first?
• Check for a blood return.
• Reposition the client's arm. Correct
• Remove the IV site dressing.
• Flush the lock with saline.
Comprehensive Hesi Fundamentals Test 2025
,Comprehensive Hesi Fundamentals Test 2025
1. The home health nurse visits an elderly female client who had a brain
attack three months ago and is now able to ambulate with the assistance of
a quad cane. Which assessment finding has the greatest implications for
this client's care?
• The husband, who is the caregiver, begins to weep when the nurse asks how he is
doing.
• The client tells the nurse that she does not have much of an appetite today.
• The nurse notes that there are numerous scatter rugs throughout the
house.Correct
• The client's pulse rate is 10 beats higher than it was at the last visit one
week ago. Scatter rugs (C) pose a safety hazard because the client can trip on
them when ambulating, so this finding has the greatest significance in
planning this client's care.Psychological support of the caregiver (A) is a less
acute need than that of client safety. The nurse needs to obtain more
information about (B), but this is not a safety issue. (D) is not a significant
increase, and additional assessment might provide information about the
reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a client. The nurse
should stop the procedure and take corrective action if which client reaction
is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the
anal sphincter, which should be stopped if the client experiences a vagal
response, such asbrady cardia (B). (A, C, and D) do not warrant stopping
the procedure.
3. The nurse is providing passive range of motion (ROM) exercises to the hip
and knee for a client who is unconscious. After supporting the client's knee
with one hand,what action should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct
Passive ROM exercise for the hip and knee is provided by supporting the
joints of the knee and ankle (D) and gently moving the limb in a slow,
smooth, firm but gentle manner. (A) should be done before the exercises are
begun to prevent injury to the nurse and client. (B) is carried out after both
,Comprehensive Hesi Fundamentals Test 2025
joints are supported. After the knee is bent, then the knee is moved toward the chest
to the point of resistance
(C) two or three times.
4. A client who has moderate, persistent, chronic neuropathic pain due to
diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin,
Advil) daily. If Step2 of the World Health Organization (WHO) pain relief
ladder is prescribed, which drug protocol should be implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin (Neurontin), an antiseizure medication, may be used at any step
for anxiety and pain management, so (A) should be implemented. Nonopiod
analgesics, such as ibuprofen
(A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics
(D), and to maintain freedom from pain, drugs should be given around the
clock rather than by the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling urinary catheter
using an open technique. What action should the nurse take after
applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe. Correct
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution.
To irrigate an indwelling urinary catheter, the nurse should first apply gloves,
then draw up the irrigating solution into the syringe (B). The syringe is then
attached to the catheter and the fluid instilled, using aseptic technique (D).
Once the irrigating solution is instilled, the client's catheter should be secured
to the drainage tubing (C). The urinary drainage bag can be emptied (A)
whenever intake and output measurement is indicated, and the instilled
irrigating fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier gloves as
required by the protocol for Standard Precautions?
• Removing the empty food tray from a client with a urinary catheter.
• Washing and combing the hair of a client with a fractured leg in traction.
• Administering oral medications to a cooperative client with a wound infection.
• Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease. Correct
, Comprehensive Hesi Fundamentals Test 2025
Possible contact with body secretions, excretions, or broken skin is an
indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage
bag requires the use of gloves (D). (A, B, and C) do not require gloves.
7. What action should the nurse implement to prevent the formation of a
sacral ulcer for a client who is immobile?
• Maintain in a lateral position using protective wrist and vest devices.
• Position prone with a small pillow below the diaphragm. Correct
• Raise the head and knee gatch when lying in a supine position.
• Transfer into a wheelchair close to the nurse's station for observation.
The prone position (B) using a small pillow below the diaphragm maintains
alignment and provides the best pressure relief over the sacral bony
prominence. Using protective (restraining) devices (A) is not indicated.
Raising the head and bed gatch
(C) may reduce shearing forces due to sliding down in bed, but it interferes
with venous return from the legs and places pressure on the sacrum,
predisposing to ulcer formation. Sitting in a wheelchair (D) places the body
weight over the ischial tuber osities and predisposes to a potential pressure
point.
8. 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?
• Check capillary refill of toes on lower extremity with Unna's paste
boot.Correct
• Apply dressing to wound area before applying the Unna's paste boot.
• Wrap the leg from the knee down towards the foot.
• 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 removedq8h. Weekly removal is
reasonable (D).
9. The nurse is administering an intermittent infusion of an antibiotic to a
client whose intravenous (IV) access is an antecubital saline lock. After
the nurse opens the roller clamp on the IV tubing, the alarm on the
infusion pump indicates an obstruction. What action should the nurse
take first?
• Check for a blood return.
• Reposition the client's arm. Correct
• Remove the IV site dressing.
• Flush the lock with saline.
