HESI FUNDAMENTALS PROCTORED EXAM ACTUAL EXAM QUESTIONS WITH DETAILED VERIFIED ANSWERS AND RATIONALE (100% CORRECT) /A+ GRADE ASSURED
HESI FUNDAMENTALS PROCTORED EXAM
ACTUAL EXAM QUESTIONS WITH
DETAILED VERIFIED ANSWERS AND
RATIONALE (100% CORRECT) 2023-
2024/A+ GRADE ASSURED
The nurse is using the Glasgow Coma Scale to perform a
neurologic assessment. A comatose client winces and pulls
away from a painful stimulus. Which action should the nurse
take next?
A. Document that the client responds to painful stimulus.
B. Observe the client’s response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider –
….ANSWER….A
Rationale: The client has demonstrated a purposeful response
to pain, which should be documented as such. Response to
painful stimulus is assessed after response to verbal stimulus,
not before. There is no indication for placing the client on
seizure precautions. Reporting decorticate posturing to the
health care provider is nonpurposeful movement.
The nurse plans to administer diazepam, 4 mg IV push, to a
client with severe anxiety. How many milliliters should the nurse
administer? (Round to the nearest tenth.)
A. 0.2 mL
B. 0.8 mL
C. 1.25 mL
D. 2.0 mL – ….ANSWER…B
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
The nurse prepares to insert a nasogastric tube in a client with
hyperemesis who is awake and alert. Which intervention(s)
is(are) correct? (Select all that apply.)
A. Place the client in a high Fowler position.
B. Help the client assume a left side-lying position.
C. Measure the tube from the tip of the nose to the umbilicus.
D. Instruct the client to swallow after the tube has passed the
pharynx.
E. Assist the client in extending the neck back so the tube may
enter the larynx. – ….ANSWER…A, D
Rationale:
(A and D) are the correct steps to follow during nasogastric
intubation. Only the unconscious or obtunded client should be
placed in a left side-lying position (B). The tube should be
measured from the tip of the nose to behind the ear and then
from behind the ear to the xiphoid process (C). The neck
should only be extended back prior to the tube passing the
pharynx and then the client should be instructed to position the
neck forward (E).
The nurse teaches the use of a gait belt to a male caregiver
whose wife has right-sided weakness and needs assistance
with ambulation. The caregiver performs a return demonstration
of the skill. Which observation indicates that the caregiver has
learned how to perform this procedure correctly?
A. Standing on his wife’s strong side, the caregiver is ready to
hold the gait belt if any evidence of weakness is observed.
B. Standing on his wife’s weak side, the caregiver provides
security by holding the gait belt from the back.
C. Standing behind his wife, the caregiver provides balance by
holding both sides of the gait belt.
D. Standing slightly in front and to the right of his wife, the
caregiver guides her forward by gently pulling on the gait belt. –
….ANSWER…B
Rationale: His wife is most likely to lean toward the weak side
and needs extra support on that side and from the back to
prevent falling. Options A, C, and D provide less security for
her.
Which nursing diagnosis has the highest priority when planning
care for a client with an indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection – ….ANSWER…D
Rationale: Indwelling urinary catheters are a major source of
infection. Options A and B are both problems that may require
an indwelling catheter. Option C is not affected by an indwelling
catheter.
A client has a nursing diagnosis of Altered sleep patterns
related to nocturia. Which client instruction is important for the
nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. –
….ANSWER…A
Rationale: Nocturia is urination during the night. Option A is
helpful to decrease the production of urine, thus decreasing the
need to void at night. Option B helps prevent bladder infections.
Option C may promote sleep, but the fluid will contribute to
nocturia. Option D may result in urinary incontinence if the
client is sedated and does not awaken to void.
When performing sterile wound care in the acute care setting,
the nurse obtains a bottle of normal saline from the bedside
table that is labeled “opened” and dated 48 hours prior to the
current date. Which is the best action for the nurse to take?
A. Use the normal saline solution once more and then discard.
B. Obtain a new sterile syringe to draw up the labeled saline
solution.
C. Use the saline solution and then relabel the bottle with the
current date.
D. Discard the saline solution and obtain a new unopened
bottle. – ….ANSWER…D
Rationale: Solutions labeled as opened within 24 hours may be
used for clean procedures, but only newly opened solutions are
considered sterile. This solution is not newly opened and is out
of date, so it should be discarded. Options A, B, and C describe
incorrect procedures.
Based on the nursing diagnosis of risk for infection, which
intervention is best for the nurse to implement when providing
care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers. – ….ANSWER…A
Rationale: The best action to decrease the risk of infection in
vulnerable clients is handwashing. Option B is not necessary
unless the client has an infection. Option C increases the risk of
infection. Option D does not reduce the risk of infection.
When taking a client’s blood pressure, the nurse is unable to
distinguish the point at which the first sound was heard. Which
is the best action for the nurse to take?
A. Deflate the cuff completely and immediately reattempt the
reading.
B. Reinflate the cuff completely and leave it inflated for 90 to
110 seconds before taking the second reading.
C. Deflate the cuff to zero and wait 30 to 60 seconds before
reattempting the reading.
D. Document the exact level visualized on the
sphygmomanometer where the first fluctuation was seen. –
….ANSWER…C
Rationale: Deflating the cuff for 30 to 60 seconds allows blood
flow to return to the extremity so that an accurate reading can
be obtained on that extremity a second time. Option A could
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