2025 HESI Fundamentals All Versions V1–V3 | 300 Actual Exam
Questions & Verified Answers with Rationales (Graded A+)
Question 1
A nurse is caring for an older adult client who is at risk for falls. Which of the following
actions should the nurse take to prevent falls?
A. Keep the bed in a high position at all times.
B. Encourage the use of socks when ambulating.
C. Leave the room lights off at night.
D. Place the call light within the client’s reach.
Answer: D. Place the call light within the client’s reach.
Rationale: Placing the call light within reach promotes client safety and reduces the risk of
falls by allowing the client to ask for assistance before attempting to ambulate.
Question 2
Which of the following actions should the nurse take when measuring a client's radial
pulse?
A. Use the thumb to palpate the pulse.
B. Measure for 15 seconds and multiply by 4.
C. Apply moderate pressure over the radial artery.
, D. Ask the client to talk during measurement.
Answer: C. Apply moderate pressure over the radial artery.
Rationale: Using moderate pressure allows accurate palpation of the radial pulse without
occluding the artery.
Question 3:
A nurse is providing oral care for an unconscious client. Which of the following actions
should the nurse take?
A. Place the client in a supine position.
B. Use a firm-bristled toothbrush.
C. Position the client on their side.
D. Insert fingers into the mouth to hold it open.
Answer: C. Position the client on their side.
Rationale: Placing the client in a lateral position promotes drainage and prevents
aspiration during oral care.
Question 4
A nurse is preparing to administer a subcutaneous injection of heparin. Which of the
following is an appropriate technique?
A. Massage the site after injection.
B. Use a 22-gauge, 1.5-inch needle.
, C. Insert the needle at a 90-degree angle.
D. Administer in the deltoid muscle.
Answer: C. Insert the needle at a 90-degree angle.
Rationale: Heparin is administered subcutaneously at a 90-degree angle using a short
needle, typically in the abdomen, without massaging the site.
Question 5
A nurse is reinforcing teaching with a client about how to use an incentive spirometer.
Which of the following instructions should the nurse include?
A. Exhale forcefully into the spirometer.
B. Inhale slowly to raise the piston.
C. Use the device once per day.
D. Perform the exercise while lying flat.
Answer: B. Inhale slowly to raise the piston.
Rationale: Instructing the client to inhale slowly helps maximize lung expansion and
prevents atelectasis.
Question 6
A nurse is documenting a pressure ulcer using the staging system. A shallow open ulcer
with a red-pink wound bed is consistent with which stage?
A. Stage I
, B. Stage II
C. Stage III
D. Stage IV
Answer: B. Stage II
Rationale: A Stage II pressure ulcer is characterized by partial-thickness skin loss with a
red-pink wound bed, without slough.
Question 7
A nurse is caring for a client who has Clostridium difficile. Which of the following infection
control precautions should be implemented?
A. Use alcohol-based hand sanitizer.
B. Place the client in a negative-pressure room.
C. Wear a gown and gloves when entering the room.
D. Place the client in airborne isolation.
Answer: C. Wear a gown and gloves when entering the room.
Rationale: Contact precautions, including the use of gown and gloves, are necessary for C.
difficile due to its high risk of environmental contamination.
Question 8
Which of the following findings requires immediate intervention by the nurse?
Questions & Verified Answers with Rationales (Graded A+)
Question 1
A nurse is caring for an older adult client who is at risk for falls. Which of the following
actions should the nurse take to prevent falls?
A. Keep the bed in a high position at all times.
B. Encourage the use of socks when ambulating.
C. Leave the room lights off at night.
D. Place the call light within the client’s reach.
Answer: D. Place the call light within the client’s reach.
Rationale: Placing the call light within reach promotes client safety and reduces the risk of
falls by allowing the client to ask for assistance before attempting to ambulate.
Question 2
Which of the following actions should the nurse take when measuring a client's radial
pulse?
A. Use the thumb to palpate the pulse.
B. Measure for 15 seconds and multiply by 4.
C. Apply moderate pressure over the radial artery.
, D. Ask the client to talk during measurement.
Answer: C. Apply moderate pressure over the radial artery.
Rationale: Using moderate pressure allows accurate palpation of the radial pulse without
occluding the artery.
Question 3:
A nurse is providing oral care for an unconscious client. Which of the following actions
should the nurse take?
A. Place the client in a supine position.
B. Use a firm-bristled toothbrush.
C. Position the client on their side.
D. Insert fingers into the mouth to hold it open.
Answer: C. Position the client on their side.
Rationale: Placing the client in a lateral position promotes drainage and prevents
aspiration during oral care.
Question 4
A nurse is preparing to administer a subcutaneous injection of heparin. Which of the
following is an appropriate technique?
A. Massage the site after injection.
B. Use a 22-gauge, 1.5-inch needle.
, C. Insert the needle at a 90-degree angle.
D. Administer in the deltoid muscle.
Answer: C. Insert the needle at a 90-degree angle.
Rationale: Heparin is administered subcutaneously at a 90-degree angle using a short
needle, typically in the abdomen, without massaging the site.
Question 5
A nurse is reinforcing teaching with a client about how to use an incentive spirometer.
Which of the following instructions should the nurse include?
A. Exhale forcefully into the spirometer.
B. Inhale slowly to raise the piston.
C. Use the device once per day.
D. Perform the exercise while lying flat.
Answer: B. Inhale slowly to raise the piston.
Rationale: Instructing the client to inhale slowly helps maximize lung expansion and
prevents atelectasis.
Question 6
A nurse is documenting a pressure ulcer using the staging system. A shallow open ulcer
with a red-pink wound bed is consistent with which stage?
A. Stage I
, B. Stage II
C. Stage III
D. Stage IV
Answer: B. Stage II
Rationale: A Stage II pressure ulcer is characterized by partial-thickness skin loss with a
red-pink wound bed, without slough.
Question 7
A nurse is caring for a client who has Clostridium difficile. Which of the following infection
control precautions should be implemented?
A. Use alcohol-based hand sanitizer.
B. Place the client in a negative-pressure room.
C. Wear a gown and gloves when entering the room.
D. Place the client in airborne isolation.
Answer: C. Wear a gown and gloves when entering the room.
Rationale: Contact precautions, including the use of gown and gloves, are necessary for C.
difficile due to its high risk of environmental contamination.
Question 8
Which of the following findings requires immediate intervention by the nurse?
