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2022 HESI RN FUNDAMENTALS EXAM BUNDLE | 2019 - 2022 Exams Compiled 100% Verified Q&A | Best for 2023 Test Revision
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2022 HESI RN FUNDAMENTALS EXAM & 2019 TEST BANK Q&A 100% Verified
HESI RN FUNDAMENTALS SAMPLE QUESTIONS/ PREVIEW - The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter a... [Show More] larm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? exchange pulse ox for another monitor - Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse to include in the client’s plan of care? The client will Ambulate without discomfort -After assessing a client, the nurse identifies three nursing problems. When developing the client’s plan of care, which action should the nurse take next? Prioritize the identified nursing diagnoses 1. The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. 2. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 3. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. 4. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. 5. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 6. The charge nurse observes a new graduate nurse demonstrate the administration of two different liquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residual Add the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately 7. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action should the nurse take nest? Apply intermittent suction 8. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, what action should the nurse implement? Instruct the client to use guided imagery and slow rhythmic breathing. 9. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP? Wear gloves while giving a bath 10. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s room. 11. The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? An older male with multiple problems, including obesity, diabetes, and hypertension. 12. It is most important for the nurse to recalculate the Braden scale for a client who has developed which problem? Urinary incontinence 13. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths between the top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching the client how to walk with the crutches. 14. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how should the nurse respond? Encourage discussion about the concern and fears. 15. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform which client assessment? Vital signs 16. The mother of a child with Tetrology of Fallot ask the nurse, “Why did this happen to my baby? What did I do wrong?” Which response is most helpful? “This must be a very difficult time for you.” 17. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling urinary catheter. Which intervention should the nurse implement? Use sterile syringe [Show Less]
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HESI RN Fundamentals Exam
HESI RN Fundamentals Exam 1.ID: 311236316 An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the cli... [Show More] ent's nursing care? Massage any reddened areas for at least five minutes. Encourage active range of motion exercises on extremities. Position the client laterally, prone, and dorsally in sequence. Gently lift the client when moving into a desired position. Correct To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Awarded 0.0 points out of 1.0 possible points. 2.ID: 311259558 The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? Clamp the tube for 20 minutes. Flush the tube with water. Correct Administer the medications as prescribed. Crush the tablets and dissolve in sterile water. The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Awarded 0.0 points out of 1.0 possible points. 3.ID: 311201102 A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? Give an around-the-clock schedule for administration of analgesics. Correct Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Awarded 0.0 points out of 1.0 possible points. 4.ID: 311212896 When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? Loosen the right wrist restraint. Correct Apply a pulse oximeter to the right hand. Compare hand color bilaterally. Palpate the right radial pulse. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Awarded 0.0 points out of 1.0 possible points. 5.ID: 311205664 The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. Correct A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer. A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Awarded 0.0 points out of 1.0 possible points. 6.ID: 311269346 A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? Contact the healthcare provider and complete a medication variance form. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. Notify the charge nurse and complete an incident report to explain the missed dose. Give the missed dose at 1300 and change the schedule to administer daily at 1300. Correct To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Awarded 0.0 points out of 1.0 possible points. 7.ID: 311199864 While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? Acknowledge that she is supporting the arm correctly. Correct Encourage her to keep the joint covered to maintain warmth. Reinforce the need to grip directly under the joint for better support. Instruct her to grip directly over the joint for better motion. The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Awarded 0.0 points out of 1.0 possible points. 8.ID: 311223480 What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? It is more difficult to find a superficial vein in the feet and ankles. A decreased flow rate could result in the formation of a thrombosis. Correct A cannulated extremity is more difficult to move when the leg or foot is used. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Awarded 0.0 points out of 1.0 possible points. 9.ID: 311194937 The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? [Show Less]
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2021/2022 HESI RN Fundamentals Exam | 4 Versions Combined 100% Verified Q&A
HESI RN Fundamentals Exam 4 Versions Combined 1) A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescr... [Show More] ibes an analgesic every four hours as needed. Which action should the LPN/LVN implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. Correct Answer: A 2) When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the LPN implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. Correct Answer: A 3) The LPN/LVN is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. Correct Answer: B 4) A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the LPN/LVN to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. Correct Answer: D 5) While instructing a male client's wife in the performance of passive rangeof- motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the LPN/LVN implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. Correct Answer: A 6) What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Correct Answer: B 7) The LPN observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. Correct Answer: B 8) A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The LPN plans to administer the IVPB dose over 20 minutes. For how many ml/ hr should the infusion pump be set to deliver the secondary infusion? Correct Answer: 150 9) Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the LPN/LVN? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat. Correct Answer: D 10) The LPN is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? A. If I exercise at least two times weekly for one hour, I will lower my cholesterol. B. I need to avoid eating proteins, including red meat. C. I will limit my intake of beef to 4 ounces per week. D. My blood level of low density lipoproteins needs to increase. Correct Answer: C 11) The UAPs working on a chronic neuro unit ask the LPN/LVN to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A. [Show Less]
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2021/ 2022 HESI RN Fundamentals Exam | 3 Versions combined | 100% Verified Q&A
HESI RN Fundamentals Exam 3 Versions combined 1. a nurse in a clinical is caring for a middle age adult who states, "the doctor says that since I am at ... [Show More] an average risk for colon cancer, I should have a routine screening. what does that involve?" which of the following responses should the nurse make? A. "I'll get a blood sample from you and send it for a screening test." B. "beginning at age 60, you should have a colonoscopy." C. "you should have a decal occult blood test every year." D. "the recommendation is to have a sigmoidoscopy every 10 years." "You should have a fecal occult blood test every year." Colorectal cancer screening for clients at average risk begins at age 50. Oneoption for screening is a fecal occult blood test annually. 2. a nurse is caring for a client who is having difficulty breathing. the client is laying in bed with a nasal cannula delivering oxygen. which of the following intervention should the nurse take first? A. suction the client's airway B. administer a bronchodilator C. increase the humidity in the client's room D. assist the client to an upright position assist the client to an upright position When providing client care, the nurse should first use the least invasive intervention. Therefore, the nurse should elevate the head of the client's bed tothe semi-Fowler's or high Fowler's position to facilitate maximal chest expansion. Sitting upright improves gas exchange and prevents pressure on thediaphragm from abdominal organs. 3. a nurse is preparing to administer 0.5 mL of oral single-dose liquid medication to a client. which of the following actions should the nurse take? A. gently shake the container of medication prior to administration B. transfer the medication to a medicine cup C. place the client in a semi-fowlers position to medication administration D. verify the dosage by measuring the liquid before administering it Gently shake the container of medication prior to administration. The nurse should gently shake the liquid medication to ensure the medication ismixed. 4. a nurse is planning care to improve self-feeding for a client who has visionloss. which of the following interventions should the nurse include in the plan of care? A. tell the client which food she should eat first B. provide small-handle utensils for the client C. thicken liquids on the client's tray D. use a clock pattern to describe food on the client's plate Use a clock pattern to describe food on the client's plate. Use a clock pattern to describe food on the client's plate.MY ANSWERDescribing the location of the food on the plate by using a clock patternallows the client to have greater independence during meals. 5. a nurse is teaching an older adult client who is at risk for osteoporosis aboutbeginning a program of regular physical activity. which of the following types of activity should the nurse recommend? A. walking briskly B. riding a bicycle C. performing isometric exercises D. engaging in high-impact aerobics walking briskly Weight-bearing exercises are essential for maintaining bone mass, which helps toprevent osteoporosis. Walking engages older adult clients in this preventive and therapeutic strategy. 6. a nurse is assessing a client's readiness to learn about insulin administration. which of the following statements should the nurse identify as an indication that the client is ready to learn? A. "I can concentrate best in the morning." B. "it is difficult to read the instructions because my glasses are at home." C. "I'm wondering why I need to learn this." D. "you will have to talk to my wife about this." "I can concentrate best in the morning." The client's statement indicates a readiness to learn because he is verbalizing thebest time for him to learn. 7. a nurse is giving discharge instructions to a client who will require oxygen therapy at home. which of the following statements should the nurse identify as an indication that the client understands how to manage this therapy at home? A. "I'll make sure that, when my friend comes by, she smokes at least 6 feet away from my oxygen tank." B. "I'll use a woolen blanket if I get chilly while I'm using my oxygen." C. "I'll check the wires and cables on my TV to make sure they are in good working order." D. "I'll lay my oxygen tank down on the floor when the grandchildren visit so they don't knock it over." "I'll check the wires and cables on my TV to make sure they are in good workingorder." Oxygen is a highly flammable gas. The client should make sure any electrical equipment in the room where she is using supplemental oxygen is functioning properly so it does not create any electrical sparks. 8. a nurse is caring for a client who is reporting difficulty falling asleep. which of the following measures should the nurse recommend? A. drink a cup of hot cocoa before bedtime B. exercise 1 hr before going to bed C. use progressive relaxation techniques at bedtime D. reflect on the day's activities before going to bed Use progressive relaxation techniques at bedtime. Progressive relaxation promotes sleep by decreasing stress and reducing muscle tension. 9. a nurse is assisting a client who is postoperative with the use of an incentive spirometer. into which of the following positions should the nurse place the client? A. side-lying B. supine C. semi-fowlers D. trendelenburg Semi-Fowler's Positioning the client in semi-Fowler's or high-Fowler's position allows formaximum expansion of the lungs. 10. a nurse is assessing an adult client who has been immobile for the past 3 week. the nurse should identify that which of the following findings requires further intervention? A. erythema on pressure points B. lower-extremity pulse strength on 2+ C. fluid intake of 3,000 mL per day D. a bowel movement every other day Erythema on pressure points Erythema on pressure points requires prompt relief of pressure and additional measures to protect the skin from further breakdown. 11. a nurse is caring for a client who requires a 24-hour urine collection. which [Show Less]
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HESI RN Fundamentals Exam An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing ca... [Show More] re? A. Massage any reddened areas for at least five minutes. B. Encourage active range of motion exercises on extremities. C. Position the client laterally, prone, and dorsally in sequence. D. Gently lift the client when moving into a desired position. To avoid shearing forces when repositioning, the client should be lifted gently across a surface (D). Reddened areas should not be massaged (A) since this may increase the damage to already traumatized skin. To control pain and muscle spasms, active range of motion (B) may be limited on the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip. Correct Answer: D The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? A. Clamp the tube for 20 minutes. B. Flush the tube with water. C. Administer the medications as prescribed. D. Crush the tablets and dissolve in sterile water. The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed. Correct Answer: B A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? A. Give an around-the-clock schedule for administration of analgesics. B. Administer analgesic medication as needed when the pain is severe. C. Provide medication to keep the client sedated and unaware of stimuli. D. Offer a medication-free period so that the client can do daily activities. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks (B). Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized (C). Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain (D). Correct Answer: A When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A. Loosen the right wrist restraint. B. Apply a pulse oximeter to the right hand. C. Compare hand color bilaterally. D. Palpate the right radial pulse. The priority nursing action is to restore circulation by loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to mechanical compression (the restraints). Correct Answer: A The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. Correct Answer: B A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? A. Contact the healthcare provider and complete a medication variance form. B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning. C. Notify the charge nurse and complete an incident report to explain the missed dose. D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. To ensure that a therapeutic level of medication is maintained, the nurse should administer the missed dose as soon as possible, and revise the administration schedule accordingly to prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion. The wife is performing the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the body should remain covered for warmth and privacy. (C and D) do not provide adequate support to the joint while still allowing for joint movement. Correct Answer: A What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. Venous return is usually better in the upper extremities. Cannulation of the veins in the lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be life-threatening. Superficial veins are often very easy (A) to find in the feet and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not the most important reason for using the upper extremities. Pain (D) is not a consideration. Correct Answer: B [Show Less]
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HESI RN FUNDAMENTALS EXAM & PRACTICE TEST BANK | 100% VERIFIED Q&A
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administer a dose that is not w... [Show More] ithin the prescribed parameters. What action should the nurse take first? C A) Determine if the pain was relieved. B) Complete a medication error report. C) Assess for side effects of the medication. D) Document the clients responses. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) ABDE A) Multiple hard pellets. B) Brown liquid. C) Formed but soft. D) Solid with red streaks. E) Tarry appearance. An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? A A) The importance of using vaginal lubricants. B) Methods used to practice safe sex. C) Information about alternative ways to express sexuality. D) Intercourse positions that help prevent tears. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit In a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? A) Have the client put both arms around the nurse’s neck for support. B) Place the wheelchair on the client’s left side. C) Instruct the client to look at his feet. D) Instruct the client total slow, deep breaths while transferring. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at faster pace. C) Suggest that the the client use a wheelchair instead of a walker. D) Place client on bedrest until the healthcare provider is notified. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse administer? (Round to the nearest tenth.) 1.5mg While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? C A) Reposition the pulse oximeter clip to obtain a new reading. B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client’s nose and mouth. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A A) Discuss with the client her meaning of heroic measures. B) Obtain a “do not resuscitate” (DNR) prescription. C) Set up a family conference to discuss the client’s. D) Consult the palliative care team about client’s care. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching? A A) “Do not allow the dropper bottle to touch the eye.” B) “Administer the medication directly on the cornea.” C) “Squeeze your eye closed after administering the drops.” D) “Wash your hands after each administration of eye drops.” When assessing a client who starts to wheeze related data should obtain? D A) Presence of radiation. B) Heart sounds. C) Body temperature. D) Precipitating factors. The home health nurse is reviewing the personal care of an elderly client who lives alone.Which client assessment findings indicate the need to assign an unlicensed assistive personnel. (UAP) to provide routine foot care and file the client’s toenails? Select all that apply.) ABC A) syncope when bending. B) Hand tremors. C) Diminished visual acuity. D) Urinary incontinence. E) Shuffling gait. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client’s risk for infection related to the catheter? B A) Flush the catheter daily with sterile saline. B) Encourage increased intake of oral fluids. C) Administer a PRN antipyretic if a fever develops. D) Secure the drainage bag at bladder level during transport. To assess the quality of an adult client’s pain, what approach should the nurse use? C A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures. A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide? A) “That’s correct, you do not have long to live” D B) “Would you like me to call your minister?” C) “Don't give up, you still have chemotherapy to try.” D) “Yes, your condition is serious.” When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? C A) Apply the blood pressure cuff securely. B) Record the client’s pulse rate and rhythm. C) Position the client supine for a few minutes. D) Assist the client to stand at bedside. A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP request a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take? D When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A) Modify the nursing interventions to achieve the clients goals. B) Determine if the expected outcomes were realistic. C) Review related professional standards of care. D) Obtain current client data to compare with expected outcomes. A policy requiring the removal of acrylic nails by all nursing personnel was implemented six months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? A) Number of the staff-induced skin injuries. B) Client satisfaction survey. C) Rate of needlestick injuries by nurses. D) Healthcare-associated infection rates. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assisstive personnel (UAP) who assissting with client’s care? (Select all that apply.) A) Instruct the client about signs of orthostatic hypertension B) Determine if the client needs to have a gait belt applied C) Measure the clients vital signs before the client walks. D) Offer to assist the client to void prior to walking in the hall. E) Report the onset of any dizziness or light headedness. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for nurse to include in the teaching plan? A) Dependence. B) Toxicity. C) Interaction. D) Tolerance. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? A) The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace. B) Completing the electronic record during an interview is a legal obligation of the examining nurse. C) The nurse has limited ability to observe nonverbal communication while entering the assessment electronically. D) The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should nurse contact? A) The client’s oldest living child, a lawyer, who is visiting from out of town. B) A daughter -in-law designated as the client’s Durable Power of Attorney (DPOA). C) The client’s youngest son, identified by family members as the family spokesperson. D) The client’s spouse who lives in the independent living unit of the facility. A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions? A) Change coccyx dressing, perform tracheostomy care, restart the IV. B) Perform tracheostomy care, change coccyx dressing, restart the IV. C) Restart the IV, perform tracheotomy care, change coccyx dressing. D) Change coccyx dressing, restart the IV, perform tracheostomy care. What self-care outcome is best for the nurse to use in evaluating a client’s recovery form a stroke that resulted in left- sided hemiparesis? A) Promote independence by allowing client to perform all self-care activities. B) Participates in self-care to optimal level of capacity. C) Client verbalizes importance of hygienic practices in the recovery process. D) Self-care needs to be completed by the unlicensed assistive personnel. A female client’s significant other has been at her bedside providing reassurance and support for past 3 days, as desired by the client. The client’s estranged husband arrives and demands the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? A) Communicate the client’s wishes tall members of the multidisciplinary team. B) Encourage the client to speak with her husband regarding his disruptive behavior. C) Request a consultation with the ethics committee for resolution of the situation. D) Obtain a prescription from the healthcare provider regarding visitation privilages. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client’s room to provide family privacy. D) Sit quietly with the family to offer comfort and support. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.) 0.75 A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his legs. Which should nurse implement? A) Encourage the client to take short walks around the block. B) Explain the need to keep the head of the bed elevated. C) Advise the client to dangle his feet during meals and before bedtime. D) Instruct the client to flex both of his feet several times a day. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the draining wound. What action should the nurse implemented? A) Replace dressing with cotton pads and silk tape. B) Measure and compare ankle-brachial pressure index. C) Obtain sample of the drainage for culture. D) Apply an antibiotic ointment to the wound. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply.) A) Retake the client’s blood pressure in the opposite arm. B) Ask another nurse to assist in assessing for an apical-radial pulse deficit. C) Assign the unlicensed assistive personal to recheck the BP in an hour. D) Immediately take 2 more readings on the same arm. E) Determine the client’s activity and feelings prior to the BP measurement. A client is admitted with pneumonia and has a recent history of methicillinresistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room? A) The nurse’s stethoscope. B) Paper mask and gown. C) Bed linens D) A sputum. A middle-aged male client tells the nurse that has weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement? A) Advice the client that lifestyle changes often take several weeks to be effective. B) Determine the amount of weight the client has lost since increasing his activity. C) Encourage the client to exercise every day to eliminate bedtime wakefulness. D) Ask the client to describe the exercise schedule that he has been following. Which landmarks are useful to the nurse when administering an intramuscular injection in ventrogluteal site? A) The greater trochanter and anterior superior iliac spine. B) The knee and greater trochanter. C) The upper, outer quadrant of the buttock. D) The deltoid muscle. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? A) Determine what home remedies were used. B) Assess for the presence of an impaction. C) Obtain list of prescribed home medications. D) Evaluate stool sample for presence of blood. What information is most important for the nurse to obtain in determining a client’s need for referral for obesity counseling? A) Body weight 10% over ideal body weight. B) Body mass index greater than 35. C) Daily caloric intake of 3500 calories. D) Client’s expressed desire to lose 50 pounds. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with client. When the family leaves, what action should the nurse take first? A) Apply the restraints to maintain the client’s safety. B) Reassess the client to determine the need for continuing restraints. C) Document the time the family left and continue to monitor the client. D) Call the healthcare provider for a new prescription. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider? A) Potassium 3.1mEq/L (3.1 mmil/L) B) Sodium 142 mEq/L (142 mmol/L) C) Total calcium 9.2 mg/dl (2.3 mmol/L) D) Chloride 98 mEq/L (98 mmil/L) The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet? A) Between the toes. B) Around the ankles. C) On dorsal surfaces D) Over the heels. A 24-hour urine specimen is being collected for analysis clearance. After explaining the procedures, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take? A) Initiate the collection the foll HESI RN FUNDAMENTALS 1. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails. 2. The nurse identifies a potential for infection in a client with partialthickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's [Show Less]
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2020 HESI RN FUNDAMENTALS NEW Q&A
1. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is no... [Show More] t within the prescribed parameters. What action should the nurse take first? C A) Determine if the pain was relieved. B) Complete a medication error report. C) Assess for side effects of the medication. D) Document the client’s responses. 2. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) ABDE A) Multiple hard pellets. B) Brown liquid. C) Formed but soft. D) Solid with red streaks. E) Tarry appearance. 3. An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports are likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? A A) The importance of using vaginal lubricants. B) Methods used to practice safe sex. C) Information about alternative ways to express sexuality. D) Intercourse positions that help prevent tears. 4. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit in a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? A) Have the client put both arms around the nurse’s neck for support. B) Place the wheelchair on the client’s left side. C) Instruct the client to look at his feet. D) Instruct the client total slow, deep breaths while transferring. 5. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at a faster pace. C) Suggest that the client use a wheelchair instead of a walker. D) Place the client on bed rest until the healthcare provider is notified. 6. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled, Toradol IM 30 mg/ml, How many should the nurse administer? (Round to the nearest tenth.) 1.5mg 7. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? C A) Reposition the pulse oximeter clip to obtain a new reading. B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client’s nose and mouth. 8. An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A A) Discuss with the client her meaning of heroic measures. B) Obtain a “do not resuscitate” (DNR) prescription. C) Set up a family conference to discuss the clients. D) Consult the palliative care team about the client’s care. 9. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching? A A) “Do not allow the dropper bottle to touch the eye.” B) “Administer the medication directly on the cornea.” C) “Squeeze your eye closed after administering the drops.” D) “Wash your hands after each administration of eye drops.” 10. When assessing a client who starts to wheeze related data should obtain? D A) Presence of radiation. B) Heart sounds. C) Body temperature. D) Precipitating factors. 11. The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign unlicensed assistive personnel. (UAP) to provide routine foot care and file the client’s toenails? Select all that apply.) ABC A) syncope when bending. B) Hand tremors. C) Diminished visual acuity. D) Urinary incontinence. D) Shuffling gait. [Show Less]
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Evolve HESI Fundamentals Exam 2021
Evolve HESI Fundamentals Exam
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HESI Fundamentals Exam Pack 10 Versions | 100% Verified Q&A
HESI Fundamentals Exam Pack
10 Versions | 100% Verified Q&A
1. A nurse is providing teaching to a client who has a new med prescription. Which of the
fo... [Show More] llowing manifestations of a mild allergic reaction should the nurse include?
a. Ptosis
b. Hematuria
c. Urticaria
d. Nausea
2. A nurse is providing teaching to a client who has diabetes mellitus about performing a capillary
blood glucose test. Which of the following instructions should the nurse include in the teaching?
a. Don sterile gloves prior to puncturing the site
b. Puncture site after cleansing and before antiseptic dries.
c. Gently squeeze the puncture site until a large droplet of blood forms
d. Hold the finger to puncture above the level of the heart
3. A nurse is providing teaching to a client about reducing the adverse effects of immobility. Which of the
following statements by the client indicates an understanding of the teaching?
a. I will perform ankle and knee exercises every hour- ROM is needed to prevent contractures
b. I will hold my breath when rising from a sitting position
c. I will remove my antiembolic stockings while I am in bed
d. I will have my partner help me change positions every 4 hours
4. A nurse is monitoring a client who is receiving continuous IV fluid therapy via a peripheral vein
in the left forearm. Which of the following findings indicates that the client has developed
phelbitisat the IV site?
a. Erythema along the path of the vein
b. Pitting edema at the insertion site- infiltration since water is probably displaced.
c. Coolness of the client’s left forearm - infiltration
d. Pallor of the client’s left forearm
5. A nurse is planning care for a client who reports insomnia. Which of the following actions
should the nurse perform shortly before bedtime?
a. Provide a late supper
b. Offer a wet washcloth for the client to wash her face
c. Perform range of motion excercise
d. Prepare a hot cocoa or tea for the client
6. A nurse is providing teaching to a newly licensed nurse about the care of a client who has MRSA.
Which of the following statements by the newly licensed nurse indicates an understanding of teaching?
a. I will place the client in a private room
b. I will tell the client’s visitors to wear a mask when they are within 3 feet of the client
c. I will remove my gown after leaving the client’s room
d. I will wear an N95 respirator mask when caring for the client
7. A nurse is teaching a client who requires maximal support about how to use a two wheeled walker.
Which of the following actions by the client indicates an understanding of teaching.
a. The client moves the walker ahead 25.4cm with each step
b. The client picks up the walker with each step
c. The client stands with her elbow slightly while holding the walker
d. The client stoops slightly forward when moving the walker
8. A nurse in a provider’s office is caring for a client who states “I always have trouble sleeping”.
Which of the following actions should the nurse take first?
a. Teach the client stress reduction techniques
b. Recommend that the client avoid caffeine intake in the evening
c. Identify the client typical bedtime routine
d. Encourage the client to exercise regularly during day time hours.
9. A nurse is admitting an older adult client who is Hispanic. Which of the following cultural
should the nurse include when developing the plan of care?
a. The hispanic culture views late adulthood as a negative time in the client’s life
b. The hispanic culture identifies the eldest female family member as the decision maker
c. The Hispanic culture expects individuals to make their own decisions when death is imminent.
d. The hispanic culture expects adult children to care for older adult parents.
10. A nurse is teaching about home safety with a client. Which of the following instructions should
the nurse include?
a. Unplug electronics by grasping the cord
b. Use electrical tape to secure extension cords next to baseboards on the floor
c. To use a fire extinguisher, aim high at the top of the flames.
d. Replace carpeted floors with tile
11. A nurse is preparing to perform an admission assessment for a client who reports abdominal pain.
Which of the following actions should the nurse take?
a.) Perform deep palpation at the end of the admission assessment
b.) Auscultate the client‟s abdomen before palpation
c.) Begin palpation of the abdomen at the site of pain
d.) Assess the client‟s bowel sounds using the bell of the stethoscope
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HESI Fundamentals Exam Chapter 1 – 58 Fully Covered
HESI Fundamentals Exam Chapter 1 – 58 Fully Covered Chapter 1 1. A nurse is discussing restorative health care with a newly licensed nurse. Which of th... [Show More] e following examples should the nurse include in the teaching? (Select all that apply.) a. Home health care b. Rehabilitation facilities c. Diagnostic centers d. Skilled nursing facilities e. Oncology centers 2. A nurse is explaining the various types of health care coverage clients might have to a group of nurses. Which of the following health care financing mechanisms should the nurse include as federally funded? (Select all that apply.) a. Preferred provider organization (PPO) b. Medicare c. Long-term care insurance d. Exclusive provider organization (EPO) e. Medicaid 3. A nurse manager is developing strategies to care for the increasing number of clients who have obesity. Which of the following actions should the nurse include as a primary health care strategy? a. Collaborating with providers to perform obesity screenings during routine office visits. b. Ensuring the availability of specialized beds in rehabilitation centers for clients who have obesity. c. Providing specialized intraoperative training in surgical treatments for obesity. d. Educating acute care nurses about postoperative complications related to obesity. 4. A nurse is discussing the purpose of regulatory agencies during a staff meeting. Which of the following tasks should the nurse identify as the responsibility of state licensing boards? a. Monitoring evidence-based practice for clients who have a specific diagnosis. b. Ensuring that health care providers comply with regulations. c. Setting quality standards for accreditation of health care facilities. d. Determining whether medications are safe for administration to clients. 5. A nurse is explaining the various levels of health care services to a group of newly licensed nurses. Which of the following examples of care or care settings should the nurse classify as tertiary care? (Select all that apply.) a. Intensive care unit b. Oncology treatment center c. Burn center d. Cardiac rehabilitation e. Home health care Chapter 2 1. A nurse is caring for a group of clients on a medical surgical unit. For which of the following client care needs should the nurse initiate a referral for a social worker? (Select all that apply.) a. A client who has terminal cancer requests hospice care in the home. b. A client asks about community resources available for older adults [Show Less]
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RN HESI FUNDAMENTALS EXAM
RN HESI FUNDAMENTALS EXAM The nurse observes that a male client has removed the covering from an ice park applied to his knee. What action should the nur... [Show More] se take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. Observe the appearance of the skin under the ice pack (The first action taken by the nurse should be to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can take the other actions.) The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor of 60 gtt/mL, how many drops per minute should the client receive? 124 gtt/min The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/ 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? 83 gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? Examining a chest x-ray obtained after the tubing was inserted Three days following a 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? A. Reassure the client that he will become accustomed to the stoma appearance in time. B. Instruct the client that the stoma will become much smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. D. Encourage the client to handle the stoma equipment to gain confidence with the procedure. B. Instruct the client that the stoma will become smaller when the initial swelling diminishes (Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when swelling is diminished (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care. (D) A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use. B. Reposition the client on her side. (The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention (B) should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D)) A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? A. Record the coughing incident. No further action is required at this time. B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. demonstrates loss of remote memory B. exhibits expressive dysphasia C. has a diminished attention span D. is disoriented to place and time D. [Show Less]
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RN HESI Fundamentals Exam B
1. What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients'... [Show More] healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. C. As a tool to organize thinking and clinical decision making about clients' healthcare needs. D. To promote the management of client care in collaboration with other healthcare professionals. C (The nursing process is a problem-solving approach that provides an organized, systematic, decision making process to effectively address the client's needs and problems. The nursing process includes an organized framework using knowledge, judgments, and actions by the nurse as the client's plan of care is determined, and encompasses assessment, analysis, planning, implementation, and evaluation of client care (C). (A, B, and D) do not support the basis for using the nursing process. Correct Answer: C) 2. What activity should the nurse use in the evaluation phase of the nursing process? A. Ask a client to evaluate the nursing care provided. B. Document the nursing care plan in the progress notes. C. Determine whether a client's health problems have been alleviated. D. Examine the effectiveness of nursing interventions toward meeting client outcomes. In the nursing process, the evaluation component examines the effectiveness of nursing interventions in achieving client outcomes (D). (A) is an evaluation of client satisfaction, not outcomes. (B) is a written record of the plan of care. Although (C) may occur when client outcomes are achieved, evaluation is best determined by attainment of measurable client outcomes. Correct Answer: D 3. Which statement is an example of a correctly written nursing diagnosis statement? A. Altered tissue perfusion related to congestive heart failure. B. Altered urinary elimination related to urinary tract infection. C. Risk for impaired tissue integrity related to client's refusal to turn. D. Ineffective coping related to response to positive biopsy test results. The first part of the nursing diagnosis statement is the diagnostic label and is followed by related to the cause, which should direct the nurse to the appropriate interventions. (D) best fits this criteria. (A and B) contain a medical diagnosis. (C) includes an observable cause, but (D) focuses on the client's response, which the nurse can provide support, reflection, and dialogue. Correct Answer: D 4. What action by the nurse demonstrates culturally sensitive care? A. Asks permission before touching a client. B. Avoids questions about male-female relationships. C. Explains the differences between Western medical care and cultural folk remedies. D. Applies knowledge of a cultural group unless a client embraces Western customs. Physical contact, such as touching the head, in some cultures is a sign of respect, whereas in others, it is strictly forbidden. So asking permission before touching a client (A) demonstrates culturally sensitive care. (B, C, and D) do not demonstrate cultural awareness. Correct Answer: A 5.A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. Suggest that other cultural practices be substituted by the family members. B. Examine one's own culturally based values, beliefs, attitudes, and practices. C. Explain to the family that multiple visitors are exhausting to the client. D. Allow the situation to continue until a family member's action may harm the client. Acknowledging a client's beliefs and customs related to sickness and health care are valuable components in the plan of care that prevents conflict between the goals of nursing and the client's cultural practices. Cultural sensitivity begins with examining one's own cultural values (B) to compare, recognize, and acknowledge cultural bias. (A and C) do not consider the family's needs to care for the client and are not the best ways to cope with the nurse's frustration. Although (D) may be an option, examining one's cultural differences allows the nurse to cope, empathize, and implement culturally specific interventions pertaining to the needs of the client and the family. Correct Answer: B 6. Which technique is most important for the nurse to implement when performing a physical assessment? A. A head-to-toe approach. B. The medical systems model. C. A consistent, systematic approach. D. An approach related to a nursing model. The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems. Correct Answer: C 7.A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. Amount of liquid protein supplements consumed daily. B. Foods and liquids consumed during the past 24 hours. C. Usual weekly intake of milk products and red meats. D. Grains and legume combinations used by the client. A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be illicited after confirming the client's dietary history. Correct Answer: B 8. The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 diabetes. Which finding supports this nursing diagnosis? A. Does not check capillary blood glucose as directed. B. Occasionally forgets to take daily prescribed medication. C. Cannot identify signs or symptoms of high and low blood glucose. D. Eats anything and does not think diet makes a difference in health. The nursing diagnosis of ineffective health maintenance refers to an inability to identify, manage, and/or seek out help to maintain health, and is best exemplified in the client belief or understanding about diet and health maintenance (D). (A) indicates noncompliance with an action to be done in the management of diabetes. (B) represents inattentiveness. (C) reflects knowledge deficit. Correct Answer: D 9. 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. 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. Correct Answer: C 10.A middle-aged woman who enjoys being a teacher and mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. Generativity. B. Ego integrity. C. Identification. D. Valuing wisdom. Healthy middle-aged adults focus on establishing the next generation by nurturing and guiding, which is describe by Erikson as the developmental stage of generativity (A), and is characteristic of middle adulthood. (B, C and D) are not stages of this age group according to Erickson's psychosocial developmental theory. Correct Answer: A [Show Less]
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HESI FUNDAMENTALS EXIT EXAM
HESI FUNDAMENTALS EXIT EXAM A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurs... [Show More] e include in the teaching? 1 Maligning a person's character while threatening to do bodily harm. 2 A legal wrong committed by one person against property of another. Correct3 The application of force to another person without lawful justification. 4 Behaving in a way that a reasonable person with the same education would not. Battery means touching in an offensive manner or actually injuring another person. Battery refers to actual bodily harm rather than threats of physical or psychological harm. Battery refers to harm against persons instead of property. Behaving in a way that a reasonable person with the same education would not is the definition of negligence. 65%of students nationwide answered this question correctly. View Topics 3. 130037135 Confidence: Nailed it Stats Issue with this question? 3. Which nursing interventions require a nurse to wear gloves? (Select all that apply.) 1 Giving a back rub. Correct2 Cleaning a newborn immediately after delivery. Correct3 Emptying a portable wound drainage system. 4 Interviewing a client in the emergency department. 5 Obtaining the blood pressure of a client who is human immunodeficiency virus (HIV) positive Personal protective equipment (PPE) should be used because the newborn is covered with amniotic fluid and maternal blood. PPE should be used because the nurse may be exposed to blood and fluid that are contained in the portable wound drainage system. PPE is not required for a back rub; there is no indication that the nurse is in contact with body secretions. PPE is not necessary when conducting an interview because it is unlikely that the nurse will come in contact with the client's body fluids. PPE is not necessary when obtaining the blood pressure of a client, even if the client is HIV positive. 60%of students nationwide answered this question correctly. View Topics 4. 130036514 Confidence: Nailed it Stats Issue with this question? 4. A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence? 1 Establish long-range goals for the client. 2 Identify errors that the client can correct. Correct3 Reinforce success in tasks accomplished. 4 Demonstrate ways to promote self-reliance. Success is a basic motivation for learning. People receive satisfaction when a goal is reached. Progress toward long-range goals often is not apparent readily and may be discouraging. Constructive criticism is an important aspect of client teaching, but if it is not tempered with praise, it is discouraging. Demonstrating ways to promote self-reliance is an important part of teaching, but it probably will not motivate the client. 65%of students nationwide answered this question correctly. View Topics 5. 130044704 Confidence: Pretty sure Stats Issue with this question? 5. A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? 1 Weak upper arm strength and impaired stamina 2 Weight bearing as tolerated and unilateral paralysis 3 Partial weight bearing on the affected extremity and kyphosis Correct4 Strong upper arm strength and non–weight bearing on the affected extremity A walker with four rubber tips on the legs requires more upper body strength than a rolling walker. A client who is non–weight bearing on the affected extremity is able to use a standard walker. A rolling walker is more appropriate for a client with weak upper arm strength and impaired stamina who is less able to lift up and move a walker with four rubber tips. A client with unilateral paralysis is not a candidate for a standard walker; the client must be able to grip and lift the walker with both upper extremities and move the walker forward. A rolling walker is more appropriate for this client. A client with kyphosis is less able to lift up and move a walker with four rubber tips. 62%of students nationwide answered this question correctly. View Topics 6. 130049055 Confidence: Pretty sure Stats Issue with this question? 6. To prevent footdrop in a client with a leg cast, the nurse should: 1 Encourage complete bed rest to promote healing of the foot. 2 Place the foot in traction. Correct3 Support the foot with 90 degrees of flexion. 4 Place an elastic stocking on the foot to provide support. To prevent footdrop (plantar flexion of the foot due to weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop . Applying an elastic stocking for support also will not prevent footdrop; a firmer support is required. Test-Taking Tip: On a test day, eat a normal meal before going to school. If the test is late in the morning, take a high-protein snack with you to eat 20 minutes before the examination. The brain works best when it has the glucose necessary for cellular function. 64%of students nationwide answered this question correctly. View Topics 7. 130049079 Confidence: Nailed it Stats Issue with this question? 7. What should the nurse include in dietary teaching for a client with a colostomy? 1 Liquids should be limited to 1 L per day. 2 Non-digestible fiber and fruits should be eliminated. 3 A formed stool is an indicator of constipation. Correct4 The diet should be adjusted to include foods that result in manageable stools. Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and also produce stools that are manageable, depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Food high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet. STUDY TIP: Remember that intelligence plays a vital role in your ability to learn. However, being smart involves more than just intelligence. Being practical and applying common sense are also part of the learning experience. 66%of students nationwide answered this question correctly. View Topics 9. 130050412 Confidence: Nailed it Stats Issue with this question? 9. A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 1 Relieve bronchial spasm. 2 Increase depth of respirations. Correct3 Loosen pulmonary secretions. 4 Expel carbon dioxide from the lungs. Percussion (chest physiotherapy) loosens pulmonary secretions by mechanical means. This is accomplished by vibrations over the lung fields on the client's posterior, anterior, and lateral chest. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs. 70%of students nationwide answered this question correctly. View Topics 10. 130035441 Confidence: Pretty sure Stats Issue with this question? 10. A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider determined that there was no need to change treatment, even though the child had a history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurological impairment. Legally, who is responsible for the child's injury? 1 Health care provider, because this decision took precedence over the nurse's concern 2 Health care provider, because of total responsibility for the child's health and treatment regimen Correct3 Nurse, because failure to further question the health care provider about the child's status placed the child at risk 4 Neither, because high fevers are common in children and the health care provider had little cause for concern It is the nurse's responsibility to foresee potential harm and prevent risks by acting as a client advocate. This is not acceptable as a rationale for inaction. The nurse and health care provider share interdependent roles in the assessment and care of clients. High temperatures are common in children but are nonetheless a valid cause for concern. 71%of students nationwide answered this question correctly. View Topics 11. 130045532 Confidence: Nailed it Stats Issue with this question? 11. On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? 1 Explain why there is a need to increase activity. 2 Emphasize that with a prosthesis, there will be a return to the previous lifestyle. 3 Appear cheerful and non-critical regardless of the client's response to attempts at intervention. Correct4 Acknowledge that the client's withdrawal is an expected and necessary part of initial grieving. The withdrawal provides time for the client to assimilate what has occurred and integrate the change in body image. The client is not ready to hear explanations about why there is a need to increase activity until assimilation of the surgery has occurred. Emphasizing a return to the previous lifestyle does not acknowledge that the client must grieve; it also does not allow the client to express any feelings that life will never be the same again. In addition, it may be false reassurance. The client might feel that the nurse has no comprehension of the situation or understanding of feelings if the nurse appears cheerful and noncritical regardless of the client's response to attempts at intervention. 68%of students nationwide answered this question correctly. View Topics 12. 130049034 Confidence: Pretty sure Stats Issue with this question? 12. While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: 1 Osteoarthritis 2 Osteoporosis 3 Muscle atrophy Correct4 Contracture Immobilized clients are at high risk for the development of contractures. Contractures are characterized by permanent shortening of the muscle covering a joint. Osteoarthritis is a disease process of the weight-bearing joints due to wear and tear. Osteoporosis is a metabolic disease process in which the bones lose calcium. Muscle atrophy is a wasting and/or decrease in the strength and size of muscles due to a lack of physical activity or a neurological or musculoskeletal disorder. 1. The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? 1 Soap Incorrect2 Time 3 Water Correct4 Friction Friction is necessary for the removal of microorganisms. Although soap reduces surface tension, which helps remove debris, without friction it has minimal value. Although the length of time the hands are washed is important, without friction it has minimal value. Although water flushes some microorganisms from the skin, without friction it has minimal value. Test-Taking Tip: Answer the question that is asked. Read the situation and the question carefully, looking for key words or phrases. Do not read anything into the question or apply what you did in a similar situation during one of your clinical experiences. Think of each question as being an ideal, yet realistic, situation. 65%of students nationwide answered this question correctly. View Topics 8. 130039631 Confidence: Nailed it Stats Issue with this question? 8. A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? Incorrect1 Ask the pharmacist to provide a generic form of the medication. 2 Encourage the client to acquire the medication over the internet. Correct3 Inform the health care provider of the inability to afford the medication. 4 Suggest that the client purchase insurance that covers prescription medications. The health care provider needs to be aware of the reason for the client's lack of response to the medication so that an alternate treatment plan or financial assistance can be arranged (e.g., go to The National Council on the Aging web site [BenefitsCheckUpRx] to establish whether the client is eligible for assistance from any community, state, or federal programs or from the drug company). A health care provider may prefer the proprietary form of the medication. To ask the pharmacist to provide a generic form of the medication is unsafe. To recommend that the client obtain a generic form of the medication is not within the legal role of the nurse, unless the health care provider documents that this is acceptable. Medications purchased over the internet may be illegally imported, counterfeit, expired, or contaminated and therefore should be avoided. Although some prescription insurance plans may help to reduce the cost of some medications, the client may not be able to afford the insurance. 1. A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat? Incorrect1 Apples 2 Grapes Correct3 Apricots 4 Cranberries Lasix is potassium depleting; apricots have more than 440 mg of potassium per 100 g. Apples have about 80 to 110 mg of potassium per 100 g. Grapes have about 80 to 160 mg of potassium per 100 g, depending on the variety. Cranberries have about 65 mg of potassium per 100 g. 58%of students nationwide answered this question correctly. View Topics 2. 135007872 Confidence: Just a guess Stats Issue with this question? 2. What is the best nursing intervention to minimize perineal edema after an episiotomy? Correct1 Applying ice packs Incorrect2 Offering warm sitz baths 3 Administering aspirin prn 4 Elevating the hips on a pillow Cold causes vasoconstriction and reduces edema by lessening the accumulation of blood and lymph at the episiotomy site; cold also deadens nerve endings and lessens the pain. Heat therapy alone does not resolve perineal edema. Aspirin is contraindicated in the early postpartum period because of the risk for hemorrhage. Elevating the hips provides little or minimal perineal relief. STUDY TIP: Answer every question. A question without an answer is the same as a wrong answer. Go ahead and guess. You have studied for the test and you know the material well. You are not making a random guess based on no information. You are guessing based on what you have learned and your best assessment of the question. 68%of students nationwide answered this question correctly. View Topics 3. 140375736 Confidence: Just a guess Stats Issue with this question? 3. A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends: Incorrect1 Meatloaf and tea Correct2 Meatloaf and strawberries 3 Chicken soup and baked apple 4 Chicken soup and buttered bread The meat provides proteins and the fruit provides vitamin C; both promote wound healing. Although meatloaf provides protein, tea does not provide vitamin C. Chicken soup and a baked apple do not meet the client's need for protein or vitamin C. Chicken soup and buttered bread do not meet the client's need for protein or vitamin C. 68%of students nationwide answered this question correctly. View Topics 4. 140359979 Confidence: Just a guess Stats Issue with this question? 4. A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to: Correct1 Space activities throughout the day 2 Restrict activities and encourage bed rest 3 Teach the client about limitations imposed by the disorder Incorrect4 Have a family member stay at the bedside to give the client support Spacing activities encourages maximum functioning within the limits of the client's strength and endurance. Bed rest and limited activity may lead to muscle atrophy and calcium depletion. Teaching the limitations imposed by the disorder is necessary for lifelong psychological adjustment, but does not address the client's concerns at this time. Having a member of the family stay and give the client support should be permitted if requested by the client or family, but does not address the concerns voiced by the client. 64%of students nationwide answered this question correctly. View Topics 5. 140387132 Confidence: Just a guess Stats Issue with [Show Less]
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HESI FUNDAMENTALS 2019 EXAM
1. The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad ... [Show More] cane. Which assessment finding has the greatest implications for this client's care? • The husband, who is the caregiver, begins to weep when the nurse asks how he is doing. • The client tells the nurse that she does not have much of an appetite today. • The nurse notes that there are numerous scatter rugs throughout the house. Correct • The client's pulse rate is 10 beats higher than it was at the last visit one week ago. Scatter rugs (C) pose a safety hazard because the client can trip on them when ambulating, so this finding has the greatest significance in planning this client's care. Psychological support of the caregiver (A) is a less acute need than that of client safety. The nurse needs to obtain more information about (B), but this is not a safety issue. (D) is not a significant increase, and additional assessment might provide information about the reason for the increase (anxiety, exercise, etc.). 2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure and take corrective action if which client reaction is noted? • Temperature increases from 98.8° to 99.0° F. • Pulse rate decreases from 78 to 52 beats/min. Correct • Respiratory rate increases from 16 to 24 breaths/min. • Blood pressure increases from 110/84 to 118/88 mm/Hg. Parasympathetic reaction can occur as a result of digital stimulation of the anal sphincter, which should be stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure. 3. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? • Raise the bed to a comfortable working level. • Bend the client's knee. • Move the knee toward the chest as far as it will go. • Cradle the client's heel. Correct Passive ROM exercise for the hip and knee is provided by supporting the joints of the knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle manner. (A) should be done before the exercises are begun to prevent injury to the nurse and client. (B) is carried out after both joints are supported. After the knee is bent, then the knee is moved toward the chest to the point of resistance (C) two or three times. 4. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? • Continue gabapentin. Correct • Discontinue ibuprofen. • Add aspirin to the protocol. • Add oral methadone to the protocol. Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around the clock rather than by the client s PRN requests. 5. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? • Empty the client's urinary drainage bag. • Draw up the irrigating solution into the syringe. Correct • Secure the client's catheter to the drainage tubing. • Use aseptic technique to instill the irrigating solution. To irrigate an indwelling urinary catheter, the nurse should first apply gloves, then draw up the irrigating solution into the syringe (B). The syringe is then attached to the catheter and the fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled, the client's catheter should be secured to the drainage tubing (C). The urinary drainage bag can be emptied (A) whenever intake and output measurement is indicated, and the instilled irrigating fluid can be subtracted from the output at that time. 6. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? • Removing the empty food tray from a client with a urinary catheter. • Washing and combing the hair of a client with a fractured leg in traction. • Administering oral medications to a cooperative client with a wound infection. • Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct Possible contact with body secretions, excretions, or broken skin is an indication for wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B, and C) do not require gloves. 7. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? • Maintain in a lateral position using protective wrist and vest devices. • Position prone with a small pillow below the diaphragm. Correct • Raise the head and knee gatch when lying in a supine position. • Transfer into a wheelchair close to the nurse's station for observation. The prone position (B) using a small pillow below the diaphragm maintains alignment and provides the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in bed, but it interferes with venous return from the legs and places pressure on the sacrum, predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and predisposes to a potential pressure point. 8. 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? • Check capillary refill of toes on lower extremity with Unna's paste boot. Correct • Apply dressing to wound area before applying the Unna's paste boot. • Wrap the leg from the knee down towards the foot. • Remove the Unna's paste boot q8h to assess wound healing. 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). 9. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? • Check for a blood return. • Reposition the client's arm. Correct • Remove the IV site dressing. • Flush the lock with saline. If the client's elbow is bent, the IV may be unable to infuse, resulting in an obstruction alarm, so the nurse should first attempt to reposition the client's arm to alleviate any obstruction (B). After other sources of occlusion are eliminated, the nurse may need to check for a blood return (A), remove the dressing (C), or flush the saline lock (D) and then resume the intermittent infusion. 10. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? • Sensory pattern, area, intensity, and nature of the pain. Correct • Trigger points identified by palpation and manual pressure of painful areas. • Schedule and total dosages of drugs currently used for breakthrough pain. • Sympathetic responses consistent with onset of acute pain. The components of every pain assessment should include sensory patterns, area, intensity, and nature (PAIN) of the pain (A) and are essential in identifying appropriate therapy for the client's specific type and severity of pain, which may indicate the onset of disease progression or complications. Triggers (B), current drug usage (C), and sympathetic responses (D), such as tachycardia, diaphoresis, and elevated blood pressure, are important, but should be obtained after focusing on (A). 11. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client? • Use disposable plates and utensils. • Stay in a room with the door closed. • Dispose of soiled dressings in plastic bags that are securely closed. Correct • Others who are in the same room with the client should wear a mask. Contact precautions require the use of a barrier that prevents contact with wound secretions on soiled dressings, which are best disposed of in tightly closed plastic bags (C). (A) is not necessary with contact precautions. (B and D) should be implemented for airborne, droplet precautions, or protective environments. 12. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include the dietary plan? • Ascorbic acid. • Vitamin B12. Correct [Show Less]
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Hesi Fundamentals Practice
1. Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? Chlorothi... [Show More] azide (Diuril) Acetazolamide (Diamox) Bendroflumethiazide (Naturetin) Demecarium bromide (Humorsol) 2. A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. 3. A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. 4. The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: Promote equalization of osmotic pressures. Prevent hypoxia associated with diaphoresis. Promote integrity of intracerebral neurons. Reduce brain metabolism and limit hypoxia. 5. A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL 1.5 6. The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Risk for pressure ulcer Risk for impaired skin integrity Impaired skin integrity, related to infrequent turning and repositioning Impaired skin integrity, related to the effects of pressure and shearing force 7. A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? Stage I Stage II Stage III Unstageable A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be removed before the wound can be staged. A stage I pressure ulcer is defined as an area of persistent redness with no break in skin integrity. A stage II pressure ulcer is a partial-thickness wound with skin loss involving the epidermis, dermis, or both; the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous fat. Bone, tendon, and muscle are not exposed. 8. A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. After reporting severe pain On admission to the hospital Upon entering the operating room Before transfer to a rehabilitation facility At time of scheduling for the surgical procedure Medication reconciliation involves the creation of a list of all medications the client is taking and comparing it to the health care provider's prescriptions on admission or when there is a transfer to a different setting or service, or discharge. A change in status does not require medication reconciliation. A medication reconciliation should be completed long before entering the operating room. Total hip replacement is elective surgery, and scheduling takes place before admission; medication reconciliation takes place when the client is admitted. 9. A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? White blood cell (WBC) count of 15,000 mm3 Negative protein in the urine Blood urea nitrogen (BUN) of 20 mg/dL Prothrombin of 12.0 seconds White cell counts can increase with this drug. The expected range of the WBC count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin are not necessary and these are normal values. 10. Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? Anger Denial Depression Acceptance In the stage of acceptance, the client frequently detaches from the environment and may become indifferent to family members. In addition, the family may take longer to accept the inevitable death than does the client. Although the family may not understand the anger, dealing with the resultant behavior may serve as a diversion. Denial often is exhibited by the client and family members at the same time. During depression, the family often is able to offer emotional support, which meets their needs. 11. The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruit and vegetables Nuts and seeds Lean red meats Milk and eggs With diverticular disease the patient should avoid foods that may obstruct the diverticuli. Therefore the fiber should be digestible, such as whole grains, and cooked fruits and vegetables. Milk and eggs have no fiber content but are good sources of protein. In clients with diverticular disease, nuts and seeds are contraindicated as they may be retained and cause inflammation and infection, which is known as diverticulitis. The client should also decrease intake of fats and red meats. 12. A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation Accurate pain assessment includes pain history with the client's identification of pain location, intensity, and quality and helps the nurse to identify what pain means to the client. The pattern of pain includes time of onset, duration, and recurrence of pain and its assessment helps the nurse anticipate and meet the needs of the client. Assessment of the precipitating factors helps the nurse prevent the pain and determine it cause. Purposeless movements such as tossing and turning or involuntary movements such as a reflexive jerking may indicate pain. Physiological responses such as elevated blood pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is a subjective experience and therefore the nurse has to ask the client directly instead of accepting statement of the family members. 13. While undergoing a soapsuds enema, the client reports abdominal cramping. What action should the nurse take? Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches. Clamp the tube for 2 minutes, then restart the infusion. Abdominal cramping during a soapsuds enema may be due to too rapid administration of the enema solution. Lowering the height of the enema bag slows the flow and allows the bowel time to adapt to the distention without causing excessive discomfort. Stopping the infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the tube for several minutes then restarting the infusion may be attempted if slowing the infusion does not relieve the cramps. 14. During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? The nurse also should have instituted a plan to increase activity. The nurse provided supportive nursing care for the well-being of the client. Debridement of the pressure ulcer should have been done before the dressing was applied Treatment should not have been instituted until the health care provider's prescriptions were received. According to the Nurse Practice Act, a nurse may independently treat human responses to actual or potential health problems. An activity level is prescribed by a health care provider; this is a dependent function of the nurse. There is not enough information to come to the conclusion that debridement should have been done before the dressing was applied. Application of an emollient and reinforcing a dressing are independent nursing functions. 15. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? Ask the client if he is okay. Call security from the room. Find out if there is anyone else in the room. Ask security to make sure the room is safe Safety is the first priority when responding to a presumably violent situation. The nurse needs to have security enter the room to ensure it is safe. Then it can be determined if the client is okay and make sure that any other people in the room are safe 16. To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 4 to 8 hours 12 to 24 hours 24 to 48 hours 72 to 96 hours Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in patients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice 17. A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. Ask the client what is the client's acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes The nurse works together with the client in order to determine the tolerable level of pain. Considering that the client has chronic, not acute pain, the goal of the pain management is to decrease pain to the tolerable level instead of eliminating pain completely. Administration of pain medications around the clock will provide the stable level of pain medication in the blood and relieve the pain. Elimination of all activities that precipitate the client's pain is not possible even though the nurse will try to minimize such activities. The same pain scale should be used for assessment of the client's pain level helps to ensure consistency and accuracy in the pain assessment. Only management of acute pain such as postoperative pain requires the pain assessment at frequent intervals. 18. The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. Allergy to the medication Itching in the ear canal Drainage from the ear canal Tympanic membrane rupture Partial hearing loss in the affected ear [Show Less]
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