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HESI Fundamentals of Nursing Test Bank 2025 |
100 NCLEX-Style Questions with Rationales | A+
Guaranteed Pass Study Guide
1. Fire Safety Scenario
Question:
A nurse is working the night shift on a medical-surgical unit when she smells smoke and notices
flames coming from a trash can in one of the patient rooms. The patient is alert, oriented, and lying in
bed watching television. What is the nurse's priority action?
A. Use the nearest fire extinguisher to try to put out the fire
B. Call out to other staff to bring help
C. Remove the patient from the room and close the door
D. Pull the fire alarm and notify the hospital emergency team
✅ Correct Answer: C. Remove the patient from the room and close the door
Rationale:
The correct response follows the RACE protocol (Rescue, Alarm, Contain, Extinguish). The first
priority is to rescue the patient from immediate danger. Once the patient is safe, the nurse can activate
the fire alarm, contain the fire, and attempt to extinguish it if possible and safe to do so.
2. Medication Administration Safety
Question:
A nurse is reviewing the medication administration record (MAR) and notices that the prescribed dose
of digoxin is 1.5 mg. From her pharmacology knowledge, the nurse recalls that the usual therapeutic
dose for this patient is 0.125 mg. What action should the nurse take?
A. Hold the dose and contact the healthcare provider for clarification
B. Ask a colleague if this dose has been given before
C. Administer the medication and monitor for toxicity
D. Document the order and give the medication as written
✅ Correct Answer: A. Hold the dose and contact the healthcare provider for clarification
,2
Rationale:
The nurse has a responsibility to question any potentially harmful or incorrect medication order. A 1.5
mg dose of digoxin is dangerously high and can cause toxicity. Administering it without clarification
would constitute a medication error. The nurse should hold the dose, contact the prescriber, and clarify
before proceeding.
3. Nursing Process – Planning Stage
Question:
During the planning phase of the nursing process, a nurse is caring for a postoperative patient who has
an abdominal incision and reports pain at a level of 6 out of 10. Which of the following best reflects an
appropriate goal for this patient?
A. The nurse will administer prescribed pain medication as ordered
B. The patient will report a pain level of 3 or lower within 30 minutes of medication administration
C. The patient will remain pain-free throughout hospitalization
D. The patient will verbalize an understanding of the pain scale
✅ Correct Answer: B. The patient will report a pain level of 3 or lower within 30 minutes of
medication administration
Rationale:
During the planning phase, the nurse sets measurable and time-specific goals/outcomes. “Report a
pain level of 3 or lower within 30 minutes” is a specific, measurable, and achievable outcome.
Option A is a nursing intervention, not a goal. Option C is unrealistic, and option D focuses on
education, not pain relief.
4. Fall Risk Response
Question:
While making hourly rounds, a nurse finds a patient who is on fall precautions sitting on the floor next
to the bed. The patient appears alert but is clutching their knee and grimacing in pain. What should the
nurse do first?
A. Assist the patient back into bed and then call the healthcare provider
B. Complete an incident report as per hospital policy
C. Stay with the patient, assess for injury, and call for assistance
D. Document the fall in the nursing notes and monitor vital signs
✅ Correct Answer: C. Stay with the patient, assess for injury, and call for assistance
Rationale:
Safety and assessment come first. The nurse should stay with the patient, perform a quick assessment
(airway, breathing, circulation, pain, visible injuries), and call for help. The nurse should not move the
patient until further assessment is done. Documentation and incident reporting are important but not
the priority.
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5. Hand Hygiene Protocol
Question:
A nurse has completed a wound dressing change at the bedside of a patient with a draining abdominal
incision. After removing gloves and discarding contaminated supplies, which of the following is the
correct hand hygiene technique to prevent infection transmission?
A. Wash hands with soap and water for at least 10 seconds
B. Use alcohol-based sanitizer for 15 seconds
C. Wash hands with soap and water for at least 20 seconds
D. Rinse hands under water only if they appear clean
✅ Correct Answer: C. Wash hands with soap and water for at least 20 seconds
Rationale:
According to the CDC and standard precautions, handwashing with soap and water for 20 seconds
is required after contact with bodily fluids or contaminated materials. Alcohol-based sanitizers are
effective in many cases but not appropriate after removing gloves used for wound care.
6. Delegation and Accountability
Question:
A registered nurse (RN) is planning to delegate the task of obtaining a routine blood pressure reading
for a stable postoperative patient. Which of the following is the most appropriate action?
A. Assign the task to a nursing student on clinical rotation
B. Delegate the task to a licensed practical nurse (LPN)
C. Delegate the task to an unlicensed assistive personnel (UAP) and review the result later
D. Perform the task personally to ensure accuracy
✅ Correct Answer: C. Delegate the task to an unlicensed assistive personnel (UAP) and review
the result later
Rationale:
Vital signs for a stable patient are within the scope of practice for a UAP. The RN maintains
accountability and must review the results, but does not need to perform the task personally if
delegation is appropriate.
7. Enema Administration
Question:
The nurse is preparing to administer a cleansing enema to a patient who is scheduled for surgery in the
morning. What is the most appropriate patient position for this procedure?
A. Prone
B. Left lateral (Sim’s)
C. Right lateral
D. High Fowler’s
, 4
✅ Correct Answer: B. Left lateral (Sim’s)
Rationale:
The left lateral (Sim’s) position allows gravity to aid the flow of the enema solution into the rectum
and sigmoid colon. This is the standard position used for enema administration.
8. Infection Control – PPE Selection
Question:
A nurse is caring for a patient diagnosed with Clostridium difficile (C. diff). Which personal protective
equipment (PPE) is essential when entering the room?
A. Gloves and gown
B. Mask and gown
C. Gloves only
D. Mask, gown, and gloves
✅ Correct Answer: A. Gloves and gown
Rationale:
C. diff is transmitted via the fecal-oral route through spores. Gloves and a gown are required. Hand
washing with soap and water is mandatory — alcohol sanitizer is ineffective.
9. Documentation and Legal Risk
Question:
During shift report, a nurse notes that the previous nurse failed to document that a dressing change was
performed. What is the best course of action?
A. Document the dressing change based on the verbal report
B. Inform the charge nurse and file a formal complaint
C. Leave a note for the previous nurse to correct the documentation
D. Do not document anything unless witnessed personally
✅ Correct Answer: D. Do not document anything unless witnessed personally
Rationale:
Nurses must never chart procedures or care they did not personally witness. Documentation must
be truthful, complete, and based on direct observation or action.
10. The Nursing Process – Assessment Phase
Question:
A newly admitted patient states, “I haven’t slept well in weeks.” What is the nurse’s best initial
response during the assessment phase?
HESI Fundamentals of Nursing Test Bank 2025 |
100 NCLEX-Style Questions with Rationales | A+
Guaranteed Pass Study Guide
1. Fire Safety Scenario
Question:
A nurse is working the night shift on a medical-surgical unit when she smells smoke and notices
flames coming from a trash can in one of the patient rooms. The patient is alert, oriented, and lying in
bed watching television. What is the nurse's priority action?
A. Use the nearest fire extinguisher to try to put out the fire
B. Call out to other staff to bring help
C. Remove the patient from the room and close the door
D. Pull the fire alarm and notify the hospital emergency team
✅ Correct Answer: C. Remove the patient from the room and close the door
Rationale:
The correct response follows the RACE protocol (Rescue, Alarm, Contain, Extinguish). The first
priority is to rescue the patient from immediate danger. Once the patient is safe, the nurse can activate
the fire alarm, contain the fire, and attempt to extinguish it if possible and safe to do so.
2. Medication Administration Safety
Question:
A nurse is reviewing the medication administration record (MAR) and notices that the prescribed dose
of digoxin is 1.5 mg. From her pharmacology knowledge, the nurse recalls that the usual therapeutic
dose for this patient is 0.125 mg. What action should the nurse take?
A. Hold the dose and contact the healthcare provider for clarification
B. Ask a colleague if this dose has been given before
C. Administer the medication and monitor for toxicity
D. Document the order and give the medication as written
✅ Correct Answer: A. Hold the dose and contact the healthcare provider for clarification
,2
Rationale:
The nurse has a responsibility to question any potentially harmful or incorrect medication order. A 1.5
mg dose of digoxin is dangerously high and can cause toxicity. Administering it without clarification
would constitute a medication error. The nurse should hold the dose, contact the prescriber, and clarify
before proceeding.
3. Nursing Process – Planning Stage
Question:
During the planning phase of the nursing process, a nurse is caring for a postoperative patient who has
an abdominal incision and reports pain at a level of 6 out of 10. Which of the following best reflects an
appropriate goal for this patient?
A. The nurse will administer prescribed pain medication as ordered
B. The patient will report a pain level of 3 or lower within 30 minutes of medication administration
C. The patient will remain pain-free throughout hospitalization
D. The patient will verbalize an understanding of the pain scale
✅ Correct Answer: B. The patient will report a pain level of 3 or lower within 30 minutes of
medication administration
Rationale:
During the planning phase, the nurse sets measurable and time-specific goals/outcomes. “Report a
pain level of 3 or lower within 30 minutes” is a specific, measurable, and achievable outcome.
Option A is a nursing intervention, not a goal. Option C is unrealistic, and option D focuses on
education, not pain relief.
4. Fall Risk Response
Question:
While making hourly rounds, a nurse finds a patient who is on fall precautions sitting on the floor next
to the bed. The patient appears alert but is clutching their knee and grimacing in pain. What should the
nurse do first?
A. Assist the patient back into bed and then call the healthcare provider
B. Complete an incident report as per hospital policy
C. Stay with the patient, assess for injury, and call for assistance
D. Document the fall in the nursing notes and monitor vital signs
✅ Correct Answer: C. Stay with the patient, assess for injury, and call for assistance
Rationale:
Safety and assessment come first. The nurse should stay with the patient, perform a quick assessment
(airway, breathing, circulation, pain, visible injuries), and call for help. The nurse should not move the
patient until further assessment is done. Documentation and incident reporting are important but not
the priority.
,3
5. Hand Hygiene Protocol
Question:
A nurse has completed a wound dressing change at the bedside of a patient with a draining abdominal
incision. After removing gloves and discarding contaminated supplies, which of the following is the
correct hand hygiene technique to prevent infection transmission?
A. Wash hands with soap and water for at least 10 seconds
B. Use alcohol-based sanitizer for 15 seconds
C. Wash hands with soap and water for at least 20 seconds
D. Rinse hands under water only if they appear clean
✅ Correct Answer: C. Wash hands with soap and water for at least 20 seconds
Rationale:
According to the CDC and standard precautions, handwashing with soap and water for 20 seconds
is required after contact with bodily fluids or contaminated materials. Alcohol-based sanitizers are
effective in many cases but not appropriate after removing gloves used for wound care.
6. Delegation and Accountability
Question:
A registered nurse (RN) is planning to delegate the task of obtaining a routine blood pressure reading
for a stable postoperative patient. Which of the following is the most appropriate action?
A. Assign the task to a nursing student on clinical rotation
B. Delegate the task to a licensed practical nurse (LPN)
C. Delegate the task to an unlicensed assistive personnel (UAP) and review the result later
D. Perform the task personally to ensure accuracy
✅ Correct Answer: C. Delegate the task to an unlicensed assistive personnel (UAP) and review
the result later
Rationale:
Vital signs for a stable patient are within the scope of practice for a UAP. The RN maintains
accountability and must review the results, but does not need to perform the task personally if
delegation is appropriate.
7. Enema Administration
Question:
The nurse is preparing to administer a cleansing enema to a patient who is scheduled for surgery in the
morning. What is the most appropriate patient position for this procedure?
A. Prone
B. Left lateral (Sim’s)
C. Right lateral
D. High Fowler’s
, 4
✅ Correct Answer: B. Left lateral (Sim’s)
Rationale:
The left lateral (Sim’s) position allows gravity to aid the flow of the enema solution into the rectum
and sigmoid colon. This is the standard position used for enema administration.
8. Infection Control – PPE Selection
Question:
A nurse is caring for a patient diagnosed with Clostridium difficile (C. diff). Which personal protective
equipment (PPE) is essential when entering the room?
A. Gloves and gown
B. Mask and gown
C. Gloves only
D. Mask, gown, and gloves
✅ Correct Answer: A. Gloves and gown
Rationale:
C. diff is transmitted via the fecal-oral route through spores. Gloves and a gown are required. Hand
washing with soap and water is mandatory — alcohol sanitizer is ineffective.
9. Documentation and Legal Risk
Question:
During shift report, a nurse notes that the previous nurse failed to document that a dressing change was
performed. What is the best course of action?
A. Document the dressing change based on the verbal report
B. Inform the charge nurse and file a formal complaint
C. Leave a note for the previous nurse to correct the documentation
D. Do not document anything unless witnessed personally
✅ Correct Answer: D. Do not document anything unless witnessed personally
Rationale:
Nurses must never chart procedures or care they did not personally witness. Documentation must
be truthful, complete, and based on direct observation or action.
10. The Nursing Process – Assessment Phase
Question:
A newly admitted patient states, “I haven’t slept well in weeks.” What is the nurse’s best initial
response during the assessment phase?
