EXACT HESI Fundamentals questions with answers from actual nursing exams. Students report identical questions on their tests. Pass guaranteed.
Nursing Certifications
Detailed Answer Explanations Well-structured questions covering all topics, accompanied by organized images.
Purchase For $30/monthEXACT HESI Fundamentals questions with answers from actual nursing exams. Students report identical questions on their tests. Pass guaranteed.
An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response
It is important that you continue your medication while learning to meditate.
Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
Obtain your healthcare provider's permission before starting meditation.
Complementary therapy and western medicine can be effective for you.
Correct Answer: It is important that you continue your medication while learning to meditate.
Explanation:
When a client expresses a desire to stop prescribed medication in favor of alternative therapies, the nurse's primary responsibility is to ensure the client understands the importance of maintaining their prescribed treatment while exploring complementary approaches. Hypertension is a chronic condition that requires consistent medical management to prevent severe complications such as stroke, heart attack, and kidney damage. While spiritual meditation may provide benefits such as stress reduction and modest blood pressure control, it is not a replacement for antihypertensive medication.
It is important that you continue your medication while learning to meditate:
This is the correct answer because abruptly discontinuing antihypertensive medications can lead to rebound hypertension and other life-threatening complications. Encouraging the client to continue the prescribed medication while exploring meditation emphasizes a balanced and safe approach to managing their health. This response also respects the client’s interest in alternative therapies while reinforcing the importance of evidence-based treatment.
Why the Other Options Are Incorrect:
Spiritual meditation requires a time commitment of 15 to 20 minutes daily:
While this statement provides factual information about meditation, it does not address the immediate concern—the client's intention to stop their antihypertensive medication. The priority is to ensure medication adherence and prevent health risks before discussing the logistics of meditation practice.
Obtain your healthcare provider's permission before starting meditation:
Although it is always advisable for clients to consult their healthcare providers before making changes, meditation is generally safe and does not require medical approval to begin. This response also fails to address the urgent issue—the client’s plan to discontinue their medication.
Complementary therapy and western medicine can be effective for you:
While this option acknowledges the potential for integrative care, it does not directly address the immediate risk of stopping antihypertensive medication. The nurse must first reinforce medication adherence before discussing the compatibility of complementary and conventional therapies.
Summary:
The correct response is to reinforce the importance of continuing antihypertensive medication while exploring spiritual meditation. This approach prioritizes the client’s safety and encourages collaborative care. The other options either fail to address the risk of stopping medication or provide non-essential information that does not immediately prioritize the client's health.
The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first
Instruct the client to add regular exercise as a daily routine.
Determine if the client has been keeping a sleep diary.
Encourage the client to continue the routine until sleep is achieved.
Ask the client to describe the routine he is currently following.
Correct Answer: Ask the client to describe the routine he is currently following.
Explanation:
When a client reports continued difficulties despite following a routine, it’s important to first assess whether the client is actually performing the routine correctly or whether there are other contributing factors. Asking the client to describe the routine will help the nurse understand whether the technique is being performed properly and if any adjustments are needed. This action helps the nurse gain insight into how the client is applying the progressive muscle relaxation technique. By discussing the details of the routine, the nurse can identify any gaps or errors in execution, such as not fully relaxing the muscles, missing steps, or using improper techniques. It’s crucial to understand how the client is applying the strategy before recommending other interventions.
Why the other options are incorrect:
Instruct the client to add regular exercise as a daily routine: While regular exercise can help improve sleep quality, this action should not be the first step. It is important to understand the client's current sleep routine and ensure that they are following the recommended practices before adding new interventions. Additionally, exercise should be tailored to the client’s needs and fitness level
Determine if the client has been keeping a sleep diary: Although keeping a sleep diary is a helpful tool for tracking sleep patterns and identifying contributing factors to insomnia, the first step should be to ensure the client is performing the relaxation routine correctly. If the technique is not being implemented as intended, the sleep diary may not provide useful information at this point.
Encourage the client to continue the routine until sleep is achieved: While persistence is important in behavior modification, this approach assumes that the client is performing the routine correctly. Without verifying whether the routine is being followed properly, simply encouraging continued efforts may lead to frustration and may not address the root cause of the sleep difficulties.
Summary:
The best approach is to ask the client to describe the routine they are currently following. This allows the nurse to assess whether the technique is being done correctly and whether any adjustments are necessary before considering other interventions like exercise or a sleep diary. By first understanding the client's adherence to the current routine, the nurse can better support the client in achieving restful sleep.
An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgement
A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes.
The nurse assigned to care for the client who was at lunch at the time of the fall.
The nurse who transferred the client to the chair when the fall occurred.
The charge nurse who completed rounds 30 minutes before the fall occurred.
Correct Answer: The nurse who transferred the client to the chair when the fall occurred.
Explanation:
In a malpractice case, the nurse directly responsible for the client during the time of the injury is at the greatest risk for legal liability. If a fall occurs during a transfer, the nurse performing the transfer is responsible for ensuring safety and using proper techniques. Failure to follow standard procedures or provide adequate support may lead to injury and legal consequences for negligence. This is the correct answer because malpractice involves failure to meet the standard of care. Since the client fell during a transfer, the nurse performing the transfer is most directly responsible for ensuring safe handling and monitoring the client's condition. If improper technique or negligence occurred, this nurse is at the highest legal risk.
Why the Other Options Are Incorrect:
A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes:
While poor documentation may contribute to liability, this nurse was not present at the time of the fall. Inaccurate charting can weaken a legal defense, but it does not directly cause the injury and is less likely to result in malpractice compared to the nurse actively involved.
The nurse assigned to care for the client who was at lunch at the time of the fall:
This nurse is not directly responsible because they were not present during the fall. If the nurse properly delegated care while on break, the liability falls to the individual performing direct care (in this case, the nurse performing the transfer).
The charge nurse who completed rounds 30 minutes before the fall occurred:
The charge nurse has a supervisory role but is not directly involved in client handling. Completing rounds 30 minutes before the incident does not make this nurse liable if the fall happened under the care of another responsible nurse.
Summary:
The nurse performing the transfer is at the greatest risk for a malpractice judgment because they had direct responsibility during the time of the fall. Legal liability primarily focuses on the nurse responsible for the client’s safety during care activities, particularly when injury occurs during direct intervention like a transfer.
The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take
Infuse normal saline at a keep vein open rate.
Discontinue the IV and flush the port with heparin.
Infuse 10% dextrose and water at 54 mL/hour.
Obtain a stat blood glucose level and notify the HCP.
Correct Answer: Infuse 10% dextrose and water at 54 mL/hour.
Explanation:
When a client receiving total parenteral nutrition (TPN) experiences an interruption in their infusion, the primary concern is preventing hypoglycemia. TPN contains high concentrations of glucose, and a sudden stop can lead to a rapid drop in blood sugar levels. Administering 10% dextrose in water (D10W) at the same rate as the TPN helps maintain blood glucose levels until the new TPN solution is available. This immediate action is critical to avoid complications such as dizziness, confusion, seizures, or coma. This is the correct action because it prevents hypoglycemia by providing an alternative glucose source. Since the TPN has been interrupted, administering D10W at the same rate compensates for the loss of glucose delivery and maintains metabolic stability.
Why the Other Options Are Incorrect:
Infuse normal saline at a keep vein open rate:
This is incorrect because normal saline does not contain glucose. While it maintains IV access, it does nothing to prevent hypoglycemia, which is the primary concern when TPN is interrupted.
Discontinue the IV and flush the port with heparin:
This is incorrect because discontinuing the IV eliminates access needed for urgent interventions. Flushing with heparin maintains catheter patency but does not address the critical issue of glucose replacement.
Obtain a stat blood glucose level and notify the HCP:
This is incorrect because while monitoring blood glucose is important, immediate intervention to prevent hypoglycemia is more urgent. Delaying action until the blood glucose is measured could lead to severe hypoglycemia and related complications.
Summary:
The nurse should infuse 10% dextrose and water at 54 mL/hour to prevent hypoglycemia and maintain metabolic stability when TPN is unavailable. This action is the priority because it directly addresses the risk of low blood glucose, a potentially life-threatening complication.
An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide
Be sure to have a complete physical examination before beginning your planned exercise program.
Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.
Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.
Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
Correct Answer: Be sure to have a complete physical examination before beginning your planned exercise program.
Explanation:
It is most important for an obese client planning an intensive aerobic exercise program to undergo a complete physical examination before starting. Obesity increases the risk for cardiovascular disease, joint issues, and other health conditions that may be aggravated by strenuous exercise. A physical examination allows the healthcare provider to evaluate the client’s cardiovascular fitness, detect any underlying medical conditions, and ensure the safety of the planned program. This precaution reduces the likelihood of injury or cardiovascular events and allows for modifications to match the client’s current health status.
Why the Other Options Are Incorrect:
Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more.
While stress can trigger emotional eating, this does not address the potential physical risks of beginning a vigorous exercise program without medical clearance. Additionally, exercise is usually a positive stress reliever, not a source of added stress.
Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class.
Although exercise can help manage stress, this minimizes the value of structured stress management classes. For some individuals, these classes provide effective coping mechanisms that complement physical activity. Furthermore, this option ignores the immediate safety concerns related to initiating an intense exercise regimen.
Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.
While tracking progress can motivate a client, it is not as urgent as ensuring the client is medically fit to engage in intense physical activity. Without proper medical clearance, serious complications could arise despite the client’s motivation.
Summary:
The most important instruction is to obtain a complete physical examination before starting an intensive exercise program. This step ensures the client's safety and allows for appropriate adjustments based on medical findings. Although managing stress and tracking weight loss are beneficial, physical safety takes priority when beginning a new exercise regimen.
An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers
Generalized dry skin
Localized dry skin on lower extremities
Red flush over entire skin surface.
Rashes in axillary, groin, and skin fold regions.
Correct Answer: Rashes in axillary, groin, and skin fold regions
Explanation:
This finding indicates moisture-associated skin damage (MASD), which is a significant risk factor for pressure ulcers. Prolonged exposure to moisture from sweating, incontinence, or poor hygiene can weaken the skin barrier, causing maceration (softening and breakdown of skin). This makes the skin more vulnerable to friction, shearing, and pressure injuries—especially in areas where skin folds trap moisture. If left unaddressed, these rashes may progress to open wounds or pressure ulcers due to reduced circulation and skin integrity breakdown.
Why the Other Options Are Incorrect:
Generalized dry skin:
While dry skin can cause discomfort and itching, it does not directly increase the risk of pressure ulcers. Pressure ulcers are more likely to develop from moisture damage, friction, and prolonged immobility, rather than dry skin. Proper moisturization may help prevent cracking, but this condition alone is not a primary risk factor.
Localized dry skin on lower extremities:
Localized dryness may indicate poor circulation or dehydration, but it does not pose an immediate risk for pressure ulcers. Pressure ulcers typically form in areas where prolonged pressure restricts blood flow, not from localized dry skin.
Red flush over entire skin surface:
A red flush could indicate fever, inflammation, or allergic reactions, but it does not directly increase the risk of pressure ulcers. Pressure ulcers typically develop in areas of sustained pressure, particularly on bony prominences, and are not caused by generalized redness.
Summary:
The correct answer is Rashes in axillary, groin, and skin fold regions because moisture trapped in these areas increases the risk for skin breakdown and pressure ulcer formation. The other options describe skin conditions that may require attention but do not present the same degree of risk for pressure ulcers as moisture-related damage in skin folds.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?
Reassure the client that he will become accustomed to the stoma appearance in time.
Instruct the client that the stoma will become smaller when the initial swelling diminishes.
Offer to contact a member of the local ostomy support group to help him with his concerns.
Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Correct Answer. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
Explanation:
It is common for a colostomy stoma to appear swollen and larger immediately after surgery due to postoperative edema. This swelling typically subsides within 6 to 8 weeks as the tissues heal. By providing this information, the nurse helps to normalize the client’s concerns and reduce anxiety. Offering factual, reassuring information supports the client’s emotional adjustment and fosters trust in the care process. It also prepares the client for the natural progression of healing.
Why the Other Options Are Incorrect:
Reassure the client that he will become accustomed to the stoma appearance in time:
While adjustment is part of the process, vague reassurance does not address the immediate concern of the stoma’s size. Clients need specific information to understand what is happening and why the stoma looks different than expected.
Offer to contact a member of the local ostomy support group to help him with his concerns:
Although ostomy support groups can be beneficial, this does not address the client’s immediate worry about the size of the stoma. It may be more helpful to reassure the client about swelling first and then suggest peer support as a follow-up.
Encourage the client to handle the stoma equipment to gain confidence with the procedure:
While familiarizing the client with the stoma and equipment is an important step in long-term adjustment, it does not address the emotional distress caused by the unexpected size. Education and emotional support should come before encouraging self-care activities.
Summary:
The correct answer is instruct the client that the stoma will become smaller when the initial swelling diminishes because it directly addresses the client’s concern with a factual explanation that relieves anxiety. The other options, while helpful in the overall adjustment process, do not provide immediate or specific reassurance about the temporary nature of the stoma’s size.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide
Take a vitamin supplement tablet once a day.
Change positions in the chair at least every hour.
Increase daily intake of water or other oral fluids.
Purchase a newer model wheelchair
Correct Answer: Change positions in the chair at least every hour.
Explanation:
Redness in the sacral area is a common sign of pressure or friction, and it may be the early stage of a pressure injury or ulcer, especially for someone who is wheelchair-bound. The most important action to prevent further skin breakdown is to relieve the pressure from the affected area by changing positions regularly. The nurse should instruct the client to change positions at least every hour to reduce the prolonged pressure on the sacral area and promote blood circulation. Regular movement and repositioning help prevent pressure sores from developing or worsening, which is essential for someone who spends long periods in a wheelchair.
Why the other options are incorrect:
Take a vitamin supplement tablet once a day: While nutrition, including vitamins and minerals like vitamin C and zinc, plays a role in skin health and wound healing, it is not the most immediate or critical intervention for preventing or addressing redness from pressure. Vitamin supplementation should be considered as part of a comprehensive care plan, but it does not address the mechanical cause of the pressure injury, which is relieved by repositioning.
Increase daily intake of water or other oral fluids: Adequate hydration is essential for overall health and can help keep the skin moist and resilient. However, hydration alone will not address the specific concern of pressure on the sacral area. Repositioning is the immediate priority to reduce the risk of skin breakdown.
Purchase a newer model wheelchair: While a newer or better-fitting wheelchair might be beneficial in some cases, the key issue here is the need to relieve pressure on the sacral area. A better wheelchair alone will not prevent pressure ulcers unless the client is consistently repositioned. The nurse should focus on behavior changes (like repositioning) before considering a change in equipment.
Summary:
The most critical intervention for this client is to change positions in the chair at least every hour to prevent further pressure on the sacral area, which will help prevent the development of pressure ulcers. While other factors like hydration, nutrition, and equipment may be helpful in a broader care plan, repositioning is the most immediate and effective measure in this scenario.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse
"How will this affect your present sexual activity?"
"How active is your current sex life?"
"How has your sex life changed as you have become older?"
"Tell me about your sexual needs as an older adult."
Correct Answer: "How will this affect your present sexual activity?"
Explanation:
This response is open-ended, nonjudgmental, and client-centered, allowing the client to express concerns about how the medication’s side effects may impact their current sexual activity. It also acknowledges that older adults remain sexually active and treats the client’s concerns with respect and sensitivity. This approach helps the nurse assess the emotional and physical effects of the medication while fostering open communication.
Why the Other Options Are Incorrect:
"How active is your current sex life?"
This question is closed-ended, which may limit the client's ability to discuss feelings or concerns. It may also feel invasive or judgmental, creating discomfort and reducing trust. The phrasing focuses only on frequency rather than addressing how the medication may affect the client's quality of life.
"How has your sex life changed as you have become older?"
While this question explores changes, it shifts focus to age-related sexual changes rather than the specific impact of the medication. It could make the client feel stereotyped or dismissed, especially if they are seeking solutions to a new concern.
"Tell me about your sexual needs as an older adult."
This question is too broad and may be uncomfortable or inappropriate given the client's immediate concern about the side effects of a specific medication. It also generalizes sexual needs based on age, which may reinforce ageist assumptions.
Summary:
The best response is "How will this affect your present sexual activity?" because it directly addresses the client's concern, encourages open communication, and allows the client to express personal feelings without judgment. The other options either focus on age-related assumptions, are too broad, or limit the conversation to closed-ended responses.
The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best
Only refer to the client by gender.
Identify the client only by age.
Avoid using the client's name.
Discuss the client another time.
Correct Answer:Only refer to the client by gender.
Explanation:
When discussing a client's depression or any sensitive information in a public space such as an emergency department (ED), the nurse must maintain confidentiality and protect the client's privacy. The nurse should avoid identifying information that could make the client easily identifiable to others in the vicinity. This option helps maintain the confidentiality of the client while allowing the nurse to communicate relevant information. Referring to the client by gender is a neutral and respectful way to discuss the client’s case without disclosing personal identifiers such as name or age. This minimizes the risk of a breach of confidentiality.
Why the other options are incorrect:
Identify the client only by age: Using age could still potentially lead to identification, especially if there are only a few clients in the ED of a similar age group. Age alone could still be too specific and could compromise confidentiality.
Avoid using the client's name: While avoiding the use of the client's name is important for confidentiality, this option does not fully address the issue of privacy in the situation. Simply avoiding the name is not enough if other potentially identifying information (such as age or specific details) is shared openly.
Discuss the client another time: While it is ideal to avoid discussing sensitive information in public settings, this may not be practical if the situation requires immediate attention. The nurse should aim to balance confidentiality with the need for timely communication. Therefore, delaying the discussion may not be the most effective option, especially in an emergency setting.
Summary:
The best action is to refer to the client by gender to protect their confidentiality while still allowing necessary communication with the health care provider. This ensures that sensitive information is kept private while the nurse discusses the client’s care.
Trusted by thousands of nursing students worldwide for exam success.
