HESI Fundamentals - Set 1 - Part 1

Correct Answer: Patient reports throbbing headache since morning

Subjective data come directly from the patient's report and cannot be independently verified by another observer. The headache description is something only the patient feels and conveys through words. Option a is incorrect because A heart rate counted at the radial pulse is an objective measurement obtained through the nurse's own observation. Numbers gathered by the nurse without relying on patient report are objective findings. Option c is incorrect because Oxygen saturation read on the pulse oximeter is measured by a device and recorded by the nurse. It does not depend on the patient's perception or self-description of breathing. Option d is incorrect because Skin temperature and texture assessed through palpation come from the nurse's direct observation. These findings are confirmed by the nurse and do not rely on patient verbal report.

Correct Answer: Focused respiratory and neurologic assessment

A change in condition demands a focused assessment of the systems that explain the cues. New confusion plus dyspnea points to a possible oxygenation or neurologic problem, and that pathway needs immediate evaluation. Option a is incorrect because A complete head-to-toe takes too long for an acute change. The nurse should focus on the systems most likely to explain the new findings rather than gathering broad data right now. Option b is incorrect because A full admission assessment was already completed earlier and would only repeat baseline questions. The patient needs a quick, targeted evaluation aimed at the present cluster of new symptoms. Option d is incorrect because A full psychosocial and developmental review does not address the immediate physiologic concern. While valuable in other contexts, it is the wrong tool when oxygenation and brain perfusion may be compromised.

Correct Answer: Inspect, auscultate, percuss, then palpate

Inspection comes first, then auscultation before any touching. Palpation or percussion can stimulate or alter bowel sounds, so listening before manipulation preserves an accurate baseline of true intestinal activity. Option b is incorrect because Beginning with palpation can change bowel sound character and may worsen tenderness. Touching the abdomen before listening can produce hyperactive sounds that mislead the nurse about the patient's actual baseline. Option c is incorrect because Percussion before auscultation can also alter bowel sounds. Any mechanical contact with the abdomen, whether tapping or pressing, must follow listening so the recorded sounds reflect the true intestinal state. Option d is incorrect because Saving inspection for last loses the broad visual data that should guide the rest of the exam. The nurse needs to see distention or scars before deciding where to listen and palpate.

Correct Answer: Raise head of bed, apply oxygen

An unstable patient with low oxygen saturation needs immediate airway and breathing support. Raising the head of bed and applying oxygen treats hypoxia while focused assessment continues, addressing the most pressing physiologic threat. Option a is incorrect because A full head-to-toe takes far too long when oxygen saturation is already in the eighties. Stopping for a comprehensive assessment delays oxygen delivery and worsens tissue hypoxia in critical organs. Option b is incorrect because Documenting before intervening leaves the patient hypoxic during the time spent charting. Documentation always follows safe action when ABCs are threatened, never in place of immediate intervention at the bedside. Option c is incorrect because Waiting fifteen minutes to recheck while the patient struggles to breathe ignores accelerating respiratory failure. Hypoxia at this level can deteriorate quickly into cardiac arrest if not corrected without delay.

Correct Answer: Notify provider and place on monitor

A critical potassium of six point eight raises serious risk of cardiac dysrhythmia. Notifying the provider and placing the patient on a monitor allows fast treatment and early detection of arrhythmia before collapse. Option a is incorrect because Charting alone does not address the immediate cardiac risk linked to severe hyperkalemia. The nurse must take action because critical values demand provider notification, not simple documentation in the record. Option b is incorrect because Holding the tray does not influence the existing hyperkalemia or its cardiac danger. Diet adjustments are part of long-term management, not the urgent priority for a value already this far out of range. Option d is incorrect because Waiting eight hours to recheck while doing nothing leaves a dangerous level untreated. Hyperkalemia at six point eight can produce peaked T waves, conduction blocks, and ventricular fibrillation rather quickly.

Correct Answer: Impaired gas exchange related to alveolar changes

Impaired gas exchange names the patient response and identifies an etiology that nursing actions can address through positioning, oxygen, suctioning, and pulmonary hygiene. It fits the standard structure of a nursing diagnosis. Option b is incorrect because Community-acquired pneumonia is the disease itself, established by the medical team after imaging and cultures. Nurses do not diagnose pneumonia; they manage the human response that the disease creates. Option c is incorrect because Hypoxemia is a clinical sign defined by laboratory or oximetry data and falls under the medical diagnosis. While important, it is not a NANDA-style label describing the patient response to illness. Option d is incorrect because Streptococcal pneumonia with consolidation describes the organism and the radiographic finding, both medical territory. The nurse acts on the response such as ineffective airway clearance, not the pathogen identification itself.

Correct Answer: Risk for aspiration related to dysphagia

Risk for aspiration outranks the other options because a single aspiration event can produce pneumonia or asphyxia. Airway protection comes first, and the dysphagia cues here mark immediate, severe danger to the patient. Option a is incorrect because Chronic pain at three of ten is real but not life-threatening. Pain management matters for comfort, but it does not override an active threat to the airway from the patient's new swallowing problem. Option b is incorrect because Social isolation reflects an emotional need that fits lower on Maslow's hierarchy. The nurse must address physiologic threats first; loneliness can be supported once the patient is medically safe to swallow. Option c is incorrect because Deficient knowledge about recovery is important for discharge but not urgent right now. Teaching has no benefit if the patient suffers an aspiration event today, so airway risk takes priority over learning needs.

Correct Answer: Acute pain related to surgical incision

The cluster of high pain rating, guarding, refusal to ambulate, and shallow breathing all point directly at acute pain. The defining characteristics fit the diagnosis cleanly, and pain is driving every other finding. Option a is incorrect because Risk for falls is plausible but no falls cues are present in this stem. Without unsteady gait, sedation, or attempts to climb out of bed, there is no support for naming this the priority. Option b is incorrect because Ineffective coping has no defining cues here, since the patient has not voiced fear, anger, or maladaptive behaviors. The nurse cannot assign coping concerns based only on a refusal driven by physical pain. Option d is incorrect because Disturbed body image requires statements from the patient about appearance or scarring, none of which appear here. The cues all point to physiologic pain, not psychosocial concerns about how the body looks.

Correct Answer: Falls risk from confusion and sedation

An imminent severe risk outranks slower-developing actual problems. Climbing out of bed while sedated and unsteady creates a high chance of fracture in the next minutes, so prevention takes priority over comfort issues. Option a is incorrect because Skin redness that blanches is stage one risk for breakdown, not yet impaired skin integrity. Even if the diagnosis applied, a fall in the next minute would cause more immediate and severe harm. Option c is incorrect because Chronic incontinence is a long-standing baseline issue, not a sudden new threat. The diagnosis is real but stable; the patient will not be hurt in the next moment by ongoing urinary patterns. Option d is incorrect because Disturbed thought processes describe a contributing factor more than the chief priority itself. The nurse must act on what the confusion will cause, namely a fall, rather than the cognitive change in isolation.

Correct Answer: Impaired gas exchange related to alveolar fluid

Impaired gas exchange fits airway and breathing priority and is the most active acute threat. The crackles, tachypnea, and dyspnea all signal that oxygenation is compromised right now and needs urgent attention. Option b is incorrect because Risk for impaired skin integrity is potential, not actual, and develops over hours to days. While edema raises the risk, the threat is not as immediate as the active oxygenation problem at the bedside. Option c is incorrect because Activity intolerance is a real concern in heart failure but does not rise above breathing difficulty. The nurse can address activity limits later; correcting hypoxia and ventilation comes first using ABC priorities. Option d is incorrect because Excess fluid volume is the underlying issue producing the cues, but the ABC consequence is what the nurse treats first. Volume management follows once oxygenation has been stabilized through positioning and oxygen.

Correct Answer: Patient reports pain four within thirty minutes

This outcome is specific, measurable, time-bound, and patient-centered. The nurse can compare a numeric pain rating before and after analgesic, evaluate at thirty minutes, and decide whether to revise the plan. Option a is incorrect because Feeling better is vague and cannot be measured at any clear moment in time. There is no number, no time frame, and no observable behavior, so the outcome cannot be evaluated objectively at any point. Option b is incorrect because This sentence describes a nursing intervention rather than a patient outcome. SMART outcomes always start with the patient as the subject and describe what the patient will feel, do, know, or demonstrate. Option c is incorrect because Understand pain is not measurable since understanding has no observable form. Teach-back behavior or numeric pain ratings would be measurable; vague comprehension language gives the nurse nothing to evaluate at discharge.

Correct Answer: Raise head of bed and encourage spirometry

Repositioning and encouraging incentive spirometry are independent nursing actions. Both improve ventilation, are within standard nursing scope, and do not require a provider order before implementation in a stable patient. Option a is incorrect because Administering an antibiotic requires a provider order, since the medication, dose, route, and frequency are decided by the prescriber. The nurse implements the order but does not initiate it independently. Option b is incorrect because Ordering imaging is outside the registered nurse scope of practice in most settings. The nurse may suggest the test during communication with the provider, but only the prescriber can write the order. Option d is incorrect because Inserting a urinary catheter is a dependent intervention requiring a written order in nearly every facility. Catheter insertion also carries infection risk, which is exactly why prescriber involvement is necessary first.

Correct Answer: Consult speech-language pathologist for swallow study

A speech-language pathology consult fits a true collaborative intervention and brings expert evaluation of swallow safety. The pathologist guides diet texture and feeding strategies that prevent aspiration in the recovering stroke patient. Option b is incorrect because Placing a nasogastric tube requires a provider order and skipping the swallow workup oversteps assessment. The team should evaluate swallowing first to determine whether oral intake can be made safe. Option c is incorrect because Charting alone leaves a high-risk situation unchanged. Continuing the current diet without a swallow evaluation puts the patient at serious risk for aspiration pneumonia, which the nurse must prevent through team referral. Option d is incorrect because Verbal reassurance does not address the danger of aspiration during the next meal. Comfort statements have value alongside action, but they cannot replace the formal swallow evaluation needed for safety.

Correct Answer: Patient walks to chair with assistance today

Walking to the chair with assistance suits the patient's frailty and recent surgery while still pushing a measurable, time-bound action. The outcome is realistic, individualized, and tied to clear bedside observation today. Option a is incorrect because Running a mile by day three is unrealistic for any post-hip-repair patient and especially unsafe for a frail older adult. The outcome ignores the actual recovery trajectory and protective weight-bearing limits. Option b is incorrect because Nurse will encourage ambulation describes an intervention, not an outcome. SMART outcomes are written from the patient's viewpoint and describe what the patient will accomplish, feel, or demonstrate during the shift. Option c is incorrect because Return to baseline strength is too vague and lacks a measurable time anchor or observable behavior. Without numbers or an evaluation point, the nurse cannot decide whether the goal has been met today.

Correct Answer: Offer scheduled toileting and bedside commode

Scheduled toileting and a bedside commode address the actual driver of the unsafe behavior, which is the urge to reach the bathroom. The intervention is tailored to this patient's specific cue and need. Option a is incorrect because Call light placement is a generic universal precaution applied to every patient on the unit. While useful, the confused patient will not consistently use the call light, so the action does not solve this problem. Option b is incorrect because A low bed position is part of universal fall precautions for all patients. It helps reduce injury but does not address why this particular patient keeps trying to climb out repeatedly. Option d is incorrect because Family education has long-term value but does not change behavior tonight. The nurse needs an immediate intervention that meets the patient's elimination need before climbing happens, not a teaching plan for later.

Correct Answer: Confirm the patient identifiers and allergy

Verifying two patient identifiers and reviewing allergies before any medication is the universal safety standard. This step catches near-misses caused by misfiled charts, similar names, or undocumented allergic reactions to previous drugs. Option a is incorrect because Trust without independent verification has produced many serious errors, including wrong-patient and wrong-dose events. The current nurse remains responsible for confirming details rather than relying on a colleague's prior charting. Option c is incorrect because Skipping identifier checks for familiar patients undermines the entire two-identifier safety practice. Familiarity is exactly the condition under which look-alike errors slip through, which is why the rule applies every time. Option d is incorrect because Family confirmation is helpful but does not replace the formal verification of identifiers and allergies through the chart and patient. Family members may not know specific allergy details with full accura

Correct Answer: Outcome met as documented and continue plan

The patient achieved a measurable pain rating below five, breathing remained safe, and mobility improved. All elements of the planned outcome are present, so the nurse documents the outcome met and continues current care. Option b is incorrect because Outcome not met would require findings that the goal failed, such as continued severe pain or worsening breathing. The data here clearly show success, so revising the plan is unnecessary at this evaluation point. Option c is incorrect because Partially met would apply if some elements improved while others did not, such as pain easing while ambulation remained limited. Here every component improved, so the partial label does not fit the data. Option d is incorrect because Outcome no longer relevant only applies when the underlying diagnosis no longer exists. Acute pain still exists at three of ten, so continuing reassessment of the same outcome remains appropriate going forward.

Correct Answer: Reassess nausea level and abdomen first

Reassessment after every intervention closes the loop in the nursing process. The nurse must confirm the antiemetic worked and that the abdomen tolerates intake before introducing food that could trigger renewed vomiting. Option a is incorrect because Bringing the snack without rechecking nausea may cause vomiting if the medication has not yet worked. The nurse cannot assume effectiveness; reassessment provides the data needed to choose the next step safely. Option b is incorrect because Discontinuing the antiemetic from the plan after one dose is premature. The medication may still be needed for breakthrough nausea later in the shift, so removing it from the plan jeopardizes ongoing comfort. Option c is incorrect because Documenting that a snack was given without reassessment skips the evaluation step. Charting alone does not protect the patient from aspiration risk if nausea has actually worsened despite the recent medication dose.

Correct Answer: Reposition the patient every two hours

Repositioning is an independent nursing action used in pressure injury prevention. It requires no order, falls within standard scope, and directly addresses the diagnosis through redistribution of weight off bony prominences regularly. Option a is incorrect because Applying a prescribed ointment requires the provider order that names the medication and frequency. The nurse implements the order but does not select or initiate the antibiotic on personal judgment alone. Option b is incorrect because Urinary catheter insertion is a dependent intervention requiring a written order in nearly every facility. Catheter use also carries infection risk, which is part of why prescriber involvement is required first. Option d is incorrect because Starting intravenous fluids requires a provider order specifying the solution, rate, and indication. The nurse may suggest the order during communication, but cannot independently begin fluid therapy in standard practice.

Correct Answer: Partially met and revise interventions

Some progress occurred but neither distance nor pain target was reached. The label partially met fits, and the nurse should revise interventions, perhaps by adjusting analgesic timing or shortening walking distance per attempt. Option b is incorrect because Fully met would require both the distance and the pain target to be reached. The patient missed both benchmarks, so calling the outcome fully met misrepresents the data and risks inadequate plan revision. Option c is incorrect because Not met implies no progress occurred, which is inaccurate here since the patient walked some distance twice. Discontinuing the mobility goal would also remove a clinically necessary postoperative recovery target. Option d is incorrect because The mobility goal remains highly relevant for a postoperative patient, since walking prevents complications like pneumonia and venous thromboembolism. Removing it from the plan would harm the patient's recovery trajectory.