HESI Nursing Fundamentals EXAM NEW
VERSION LATEST UPDATE 2024-2025
WITH ACCURATE ANSWERS
GUARANTEED PASS BEST STUDYING
MATERIAL WITH 100+ QUESTIONS
A female nurse who sometimes tries to save time by putting medications in her uniform
pocket to deliver to clients, confides that after arriving home she found a hydrocodone
(Vicodin) tablet in her pocket. Which possible outcome of this situation should be the
nurse's greatest concern?
A) Accused of diversion.
B) Reported for stealing.
C) Reported for a HIPAA violation.
D) Accused of unprofessional conduct
. - ANSWERS-Answer: A
Rationale
Even if this is only one incident, the nurse may be suspected of taking medications on a
regular basis and the incident could be interpreted as diversion (A), or diverting
narcotics for her own use, which should be reported to the peer review committee and
to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most
serious possible outcome.
Which statement correctly identifies a written learning objective for a client with
peripheral vascular disease?
A) The nurse will provide client instruction for daily foot care.
B) The client will demonstrate proper trimming toenail technique.
C) Upon discharge, the client will list three ways to protect the feet from injury.
D) After instruction, the nurse will ensure the client understands foot care rationale. -
ANSWERS-Answer: C
Rationale
An objective should contain four elements: who will perform the activity or acquire the
desired behavior, the actual behavior that the learner will exhibit, the condition under
which the behavior is to be demonstrated, and the specific criteria to be used to
measure success. (C) is a concise statement that is a learning objective that defines
exactly how the client will demonstrate mastery of the content. (A, B, and D) lack one or
more of these elements.
A client with Raynaud's disease asks the nurse about using biofeedback for self-
management of symptoms. What response is best for the nurse to provide?
,A) The responses to biofeedback have not been well established and may be a waste of
time and money.
B) Biofeedback requires extensive training to retrain voluntary muscles, not involuntary
responses.
C) Although biofeedback is easily learned, it is most often used to manage exacerbation
of symptoms.
D) Biofeedback allows the client to control involuntary responses to promote peripheral
vasodilation.
- ANSWERS-Answer: D
Rationale
Biofeedback involves the use of various monitoring devices that help people become
more aware and able to control their own physiologic responses, such as heart rate,
body temperature, muscle tension, and brain waves. (D) is an accurate statement
concerning its use for clients with Raynaud's disease. (A, B, and C) do not provide
correct information about biofeedback.
A signed consent form indicated a client should have an electromyogram, but a
myelogram was performed instead. Though the myelogram revealed the cause of the
client's back pain, which was subsequently treated, the client filed a lawsuit against the
nurse and healthcare provider for performing the incorrect procedure. The court is likely
to rule in favor of the plaintiff because these events represent what infraction?
A) A quasi-intentional tort because a similar mistake can happen to anyone.
B) Failure to respect client autonomy to choose based on intentional tort law.
C) Assault and battery with deliberate intent to deviate from the consent form.
D) An unintentional tort because the client benefited from having the myelogram. -
ANSWERS-Answer C:
Rationale
The client was not properly informed of the procedure, and failure to obtain informed
consent constitutes assault and battery (C). (A) is injury to economics and dignity, such
as invasion of privacy or defamation of character. This is not an incident of failure to
respect the client's autonomy (B). An unintentional tort (D) is an act in which the
outcome was not expected, such as negligence or malpractice.
The nurse is preparing a male client who has an indwelling catheter and an IV infusion
to ambulate from the bed to a chair for the first time following abdominal surgery. What
action(s) should the nurse implement prior to assisting the client to the chair? (Select all
that apply.)
A) Pre-medicate the client with an analgesic.
B) Inform the client of the plan for moving to the chair.
C) Obtain and place a portable commode by the bed.
D) Ask the client to push the IV pole to the chair.
E) Clamp the indwelling catheter.
F) Assess the client's blood pressure.
, - ANSWERS-Answers: A, B, D, F
Rationale
The nurse should plan to implement (A, B, D, and F). Pre-medicating the client with an
analgesic (A) reduces the client's pain during mobilization and maximizes compliance.
To ensure the client's cooperation and promote independence, the nurse should inform
the client about the plan for moving to the chair (B) and encourage the client to
participate by pushing the IV pole when walking to the chair (D). The nurse should
assess the client's blood pressure (F) prior to mobilization, which can cause orthostatic
hypotension. (C and E) are not indicated.
The nurses determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate
is 125 ml/hr. What action should the nurse take first?
A) Determine when the IV solution was started.
B) Slow the IV infusion to keep vein open rate.
C) Assess the IV insertion site for swelling.
D) Report the finding to the healthcare provider.
- ANSWERS-Answer: B
Rationale
The nurse should first slow the IV flow rate to keep vein open (KVO) rate (B) to prevent
further risk of fluid volume overload, then gather additional assessment data, such as
when the IV solution was started (A) and the appearance of the IV insertion site (C)
before contacting the healthcare provider (D) for further instructions.
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?
A) Check capillary refill of toes on lower extremity with Unna's paste boot.
B) Apply dressing to wound area before applying the Unna's paste boot.
C) Wrap the leg from the knee down towards the foot.
D) Remove the Unna's paste boot q8h to assess wound healing.
- ANSWERS-Answer: A
Rationale
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 removed q8h.
Weekly removal is reasonable (D).
When preparing to administer an intravenous medication through a central venous
catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen
catheter. Which action should the nurse implement?
A) Flush the lumen with the saline solution and administer the medication through the
lumen.
, B) Determine if a PRN prescription for a thrombolytic agent is listed on the medication
record.
C) Clamp the lumen and obtain a syringe of a dilute heparin solution to flush through the
tubing.
D) Withdraw the aspirated blood into the syringe and use a new syringe to administer
the medication.
- ANSWERS-Answer: A
Rationale
Aspiration of a blood return in the lumen of a central venous catheter indicates that the
catheter is in place and the medication can be administered. The nurse should flush the
tubing with the saline solution, administer the medication (A), then flush the lumen with
saline again. (B and C) are not necessary. The aspirated blood can be flushed back
through the closed system into the client's bloodstream, but does not need to be
withdrawn (D).
While preparing to insert a rectal suppository in a male adult client, the nurse observes
that the client is holding his breath while bearing down. What action should the nurse
implement?
A) Advise the client to continue to bear down without holding his breath.
B) Gently insert the lubricated suppository four inches into the rectum.
C) Perform a digital exam to determine if a fecal impaction is present.
D) Instruct the client to take slow deep breaths and stop bearing down.
- ANSWERS-Answer: D
Rationale
During administration of a rectal suppository, the client is asked to take slow deep
breaths through the mouth to relax the anal sphincter (D). Bearing down (A) will push
the suppository out of the rectum, so the suppository should not be inserted while the
client is bearing down (B). Further data is needed before performing an invasive digital
exam to check for fecal impaction (C).
The nurse is caring for a client who is weak from inactivity because of a 2-week
hospitalization. In planning care for the client, the nurse should include which range of
motion (ROM) exercises?
A) Passive ROM exercises to all joints on all extremities four times a day.
B) Active ROM exercises to both arms and legs two or three times a day.
C) Active ROM exercises with weights twice a day with 20 repetitions each.
D) Passive ROM exercises to the point of resistance and slightly beyond.
- ANSWERS-Answer: B
Rationale
Active, rather than passive, ROM is best to restore strength and (B) is an effective
schedule. Passive ROM 4 times a day (A) is not as beneficial for the client as (B). With
weights (C), the client may fatigue quickly and develop muscle soreness. ROM is not
performed beyond the point of resistance or pain (D) because of the risk of damage to
underlying structures.
