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HESI Nclex Practice Foundations Questions and Answers | Latest Version | 2025/2026 | Correct & Verified

A nurse is preparing to take a client’s blood pressure. Which action ensures accuracy?

• Using a cuff that is too large

✔✔B. Positioning the arm at heart level

• Having the client talk during the procedure
• Applying the cuff over clothing

A nurse enters a client’s room and finds the bed in a high position with the side rails down. What is the priority action?✔✔A. Lower the bed and raise side rails

• Remind the client not to get out of bed
• Call for assistance
• Check the client’s blood pressure

A nurse is teaching a client about proper hand hygiene. Which statement shows understanding?

• "I will use cold water to wash my hands." 1 / 4

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✔✔B. "I will wash my hands for at least 20 seconds."

• "I will wear gloves instead of washing hands."
• "I only need to wash if hands look dirty."

A client is on fall precautions. Which intervention is most important?

• Encourage the client to walk alone
• Place the call light out of reach

✔✔C. Keep frequently used items within reach

• Keep the bed wheels unlocked

A nurse is assisting a client with ambulation using a gait belt. Where should the nurse stand?

• Directly behind the client

✔✔B. Slightly behind and to the side of the client

• In front of the client
• At the foot of the bed

A nurse prepares to transfer a client from bed to wheelchair. What should the nurse do first?✔✔A. Lock the wheelchair brakes 2 / 4

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• Place the footrests down
• Ask the client to cross arms
• Lower the side rails

A nurse is reinforcing teaching on the use of incentive spirometry. Which instruction is correct?

• "Exhale deeply into the device."
• "Use the device only once per day."

✔✔C. "Inhale slowly to raise the marker."

• "Hold your breath before using it."

A nurse observes a UAP providing perineal care for a female client. Which action requires intervention?

• Cleaning from front to back

✔✔B. Wiping from back to front

• Using clean gloves
• Using warm water

A nurse is preparing to perform a sterile dressing change. Which action breaks sterile technique? 3 / 4

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• Opening the sterile field away from the body

✔✔B. Turning away from the sterile field

• Pouring sterile solution onto sterile gauze
• Keeping hands above waist level

A nurse is teaching a client about the purpose of a sequential compression device (SCD). Which statement shows understanding?✔✔A. "It helps prevent blood clots in my legs."

• "It will make my legs stronger."
• "It will keep my blood pressure normal."
• "It will stop me from getting infections."

A client is placed in Trendelenburg position. What is the primary purpose?

• To reduce intracranial pressure

✔✔B. To improve venous return

• To promote lung expansion
• To prevent aspiration
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