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A BUNDLE OF HESI FUNDAMENTAL EXAM 2023/2024
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RN COMPREHENSIVE
A nurse is caring for a 5-year-old child Physical Examination: 1510: Upon visual inspection, throat is inflamed, tonsils appear pink, reddened and epi... [Show More] glottis is edematous and cherry red in appearance. Skin appears pale. Stridor noted upon inspiration with diminished bilateral lung sounds. Nurse's Notes: 1500 Child accompanied to emergency department by caregiver. Caregiver states child has a sore throat and reports the child has "pain on swallowing" and denies cough. Child is agitated and lean - ANSWERSCondition: Epiglottis Actions: Initiate droplet precautions and request a prescription for IV antibiotics Monitors: Breath sounds and temperature The nurse should anticipate initiating droplet precautions and requesting a prescription for IV antibiotics. The child is most likely experiencing epiglottis because of the clinical manifestations of a high fever, inflammation and redness of the throat, pale skin, stridor with inspiration, painful swallowing, no cough, is sitting in tripod position, and drooling. The nurse should monitor the child's temperature and breath sounds. A nurse is caring for a client who is on the spinal cord injury (SCI) unit Nurses' Notes Day 3, 1700 Client admitted to SCI unit 3 days ago following C7 injury. Skin is cool, pale, and dry to touch. Respirations easy and unlabored. Lung sounds diminished in lower lobes. Abdomen soft and nondistended with active bowel sounds. Client passed a small amount of hard formed stool this AM. Indwelling urinary catheter draining clear yellow urine. Deep tendon reflexes (DTR) are biceps 1+, triceps 1+, pa - ANSWERSThe client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. The nurse should analyze cues from the client's manifestations and determine that the client is most likely experiencing manifestations of pneumonia and autonomic dysreflexia. A client who has a cervical SCI is at risk for respiratory complications because spinal innervation to the respiratory muscles is disrupted. Adventitious breath sounds in the lower lobes bilaterally and a decrease in oxygen saturation to less than 92% can indicate pneumonia. The client's sudden increase in blood pressure, bradycardia, flushing of the skin above the area of the injury, headache, and blurred vision are manifestations of autonomic dysreflexia, which can be a life-threatening condition. A nurse is caring for a client who has abdominal pain Nurses' Notes 0900 Client reports loss of appetite, weight loss, and fatigue for 1 week. Reports abdominal pain, 6 on a scale from 0 to 10, for 2 days. Client is a perioperative nurse, returned 1 week ago from a 2-week mission trip to an underdeveloped country 1200 Results of antibody studies obtained. Provider prescription for antiviral medication pending. Physical Examination 0930 Lung sounds clear bilaterally. Skin warm to touch and jau - ANSWERSHepatitis A: Client's risk from fecal-oral transmission, laboratory results, and physical examination findings Hepatitis B: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, physical examination findings Hepatitis C: Antiviral treatment, laboratory results, client's risk from bloodborne transmission, and physical examination findings When analyzing cues, the nurse should recognize that manifestations of hepatitis A, hepatitis B, and hepatitis C include jaundice, yellow sclerae, right upper quandrant pain upon palpation, dark yellow urine, and elevated AST and ALT levels. When analyzing cues, the nurse should also recognize the client's risk for contracting hepatitis A through the fecal-oral route during recent travel to an underdeveloped country and the client's occupational risk as a perioperative nurse for contracting hepatitis B and hepatitis C through bloodborne transmission. The nurse should recognize that the current standard of practice for A nurse is caring for a client on a medical-surgical unit Vital Signs 0700 Temperature 37.6 C (99.7 F) Heart rate 100/min Respiratory rate 22/min Blood pressure 115/70 mmHg Oxygen saturation 98% on room air Nurses' Notes 1100 Client alert and oriented to person, place, and time. Client had episode of diarrhea, provided perineal care. Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum. Client repositioned every 4 hr. - ANSWERSClick to highlight the findings that require follow up. To deselect a finding, click on the finding again. - Noted 2 cm x 2 cm (0.8 in x 0.8 in) painful edematous area on sacrum - Client repositioned every 4 hr When recognizing cues, the nurse should determine that the client's painful edematous area on their sacrum and that the client has only been repositioned every 4 hr requires follow up. The client has manifestations of a pressure injury that need to be addressed. The client should be repositioned at least every 2 hr to prevent worsening of the pressure injury and to relieve pressure from the sacral area. A nurse in an outpatient mental health clinic is caring for a client Vital Signs 3 months ago Blood pressure 116/68 mmHg Heart rate 82/min Respiratory rate 16/min Temperature 36.7 C (98.1 F) SaO2 97% on room air Today: Blood pressure 128/76 mmHg Heart rate 104/min Respiratory rate 22/min Temperature 37.4 (99.4 F) SaO2 97% on room air Nurses' Notes 3 months ago Client recently admitted with new diagnosis of schizophrenia. Received inpatient treatment for 10 days and was discharged 1 week ago. - ANSWERSSelect the 3 findings that require immediate follow up: - Auditory hallucinations - Speech - Restlessness When recognizing cues, the nurse should identify that the findings of restlessness, auditory hallucinations, and pressured speech require immediate follow up. These findings are indications of psychosis. The nurse should notify the provider for additional evaluation and treatment. A nurse is caring for a client who is postoperative following coronary artery bypass surgery (CABG) Laboratory Results 0630 Sodium 145 mEq/L (136 to 145 mEq/L) [Show Less]
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HESI FUNDAMENTAL
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no uri... [Show More] ne is seen in the tubing. Which action will the nurse take next? A. Clamp the catheter and recheck it in 60 minutes. B. Pull the catheter back 3 inches and redirect upward. C. Leave the catheter in place and reattempt with another catheter. D. Notify the health care provider of a possible obstruction. - ANSWERSAnswer: C It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in place will help locate the meatus when attempting the second catheterization (C). The client should have at least 240 mL of urine after 8 hours. (A) does not resolve the problem. (B) will not change the location of the catheter unless it is completely removed, in which case a new catheter must be used. There is no evidence of a urinary tract obstruction if the catheter could be easily inserted (D). The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You" - ANSWERSAnswer: C A health promotion brochure about decreasing cholesterol (C) is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. (A) does not address the underlying causes of arteriosclerosis. (B and D) are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol (C). Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next? A. Make the client comfortable and allow the client to sleep. B. Assess the client's neurologic status. C. Notify the surgeon about the comment. D. Ask the client's family to co-sign the operative permit. - ANSWERSAnswer: B This statement may indicate that the client is confused. Informed consent must be provided by a mentally competent individual, so the nurse should further assess the client's neurologic status (B) to be sure that the client understands and can legally provide consent for surgery. (A) does not provide sufficient follow-up. If the nurse determines that the client is confused, the surgeon must be notified (C) and permission obtained from the next of kin (D). The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift. - ANSWERSAnswer: A Performing range-of-motion exercises (A) is beneficial in reducing contractures around joints. (B, C, and D) are all potentially harmful practices that place the immobile client at risk of complications. The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take? A. Check the client's carotid pulse. B. Encourage the client to get to the toilet. C. In a loud voice, call for help. D. Gently lower the client to the floor. - ANSWERSAnswer: D (D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and the nurse. Lowering the client to the floor should be done when the client cannot support his own weight. The client should be placed in a bed or chair only when sufficient help is available to prevent injury. (A) is important but should be done after the client is in a safe position. Because the client is not supporting himself, (B) is impractical. (C) is likely to cause chaos on the unit and might alarm the other clients. A female nurse is assigned to care for a close friend, who says, "I am worried that friends will find out about my diagnosis." The nurse tells her friend that legally she must protect a client's confidentiality. Which resource describes the nurse's legal responsibilities? A. Code of Ethics for Nurses B. State Nurse Practice Act C. Patient's Bill of Rights D. ANA Standards of Practice - ANSWERSAnswer: B The State Nurse Practice Act (B) contains legal requirements for the protection of client confidentiality and the consequences for breaches in confidentiality. (A) outlines ethical standards for nursing care but does not include legal guidelines. (C and D) describe expectations for nursing practice but do not address legal implications. The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first? A. Instruct the client to add regular exercise as a daily routine. B. Determine if the client has been keeping a sleep diary. C. Encourage the client to continue the routine until sleep is achieved. D. Ask the client to describe the routine that the client is currently following. - ANSWERSAnswer: D The nurse should first evaluate whether the client has been adhering to the original instructions (D). A verbal report of the client's routine will provide more specific information than the client's written diary (B). The nurse can then determine which changes need to be made (A). The routine practiced by the client is clearly unsuccessful, so encouragement alone is insufficient (C). A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? A. Take a vitamin supplement tablet once a day. B. Change positions in the chair at least every hour. C. Increase daily intake of water or other oral fluids. D. Purchase a newer model wheelchair. - ANSWERSAnswer: B The most important teaching is to change positions frequently (B) because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake (A and C) may also be beneficial promote healing and reduce further risk. (D) is an intervention of last resort because this will be very expensive for the client. 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. - ANSWERSAnswer: B 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 (B). (A) can cause client injury to the skin or joint. (C and D) are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails. A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics. - ANSWERSAnswer: C Cranberry juice (C) maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. (A, B, and D) have not been shown to be as effective as cranberry juice (C) in preventing UTIs. The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level - ANSWERSAnswer: A Long-term protein deficiency is required to cause significantly lowered serum albumin levels (A). Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. (B) is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Neither (C or D) are clinical measures of protein malnutrition. The nurse identifies a potential for infection in a patient with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful hand washing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns - ANSWERSAnswer: B Careful hand washing technique (B) is the single most effective intervention for the prevention of contamination to all clients. (A) reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. (C and D) are recommended by various burn centers as possible ways to reduce the chance of infection. (B) is a proven technique to prevent infection. [Show Less]
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HESI FUNDAMENTAL
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... [Show More] 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. - ANSWERSB 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. The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A. Administration of plasma expanders B. Use of careful handwashing technique C. Application of a topical antibacterial cream D. Limiting visitors to the client with burns - ANSWERSB Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection. The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition? A. Low serum albumin level B. Low serum transferrin level C. High hemoglobin level D. High cholesterol level - ANSWERSA Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and D are not clinical measures of protein malnutrition. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next? A. Witness the client's signature to the permit. B. Answer the client's questions about the surgery. C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered. - ANSWERSC Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained by the health care provider or surgeon, including answering the client's questions. The client's questions should be addressed before the permit is signed. The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A. Taking birth control pills for the past 2 years B. Taking anticoagulants for the past year C. Recently completing antibiotic therapy D. Having taken laxatives PRN for the last 6 months - ANSWERSB Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow? A. Place the chair parallel to the bed, with its back toward the head of the bed and assist the client in moving to the chair. B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair. C. Assist the client to a standing position by gently lifting upward, underneath the axillae. D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair. - ANSWERSB Rationale: Option B describes the correct positioning of the nurse and affords the nurse a wide base of support while stabilizing the client's knees when assisting to a standing position. The chair should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of the bed. Clients should never be lifted under the axillae; this could damage nerves and strain the nurse's back. The client should be instructed to use the arms of the chair and should never place his or her arms around the nurse's neck; this places undue stress on the nurse's neck and back and increases the risk for a fall. Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.) A. Place the client in a side-lying position. B. Pull the auricle upward and outward. C. Hold the dropper 6 cm above the ear canal. D. Place a cotton ball into the inner canal. E. Pull the auricle down and back. - ANSWERSA, B Rationale: The correct answers (A and B) are the appropriate administration of ear drops. The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E). The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug? A. "Fill your lungs with air through your mouth and then compress the inhaler." B. "Compress the inhaler while slowly breathing in through your mouth." C. "Compress the inhaler while inhaling quickly through your nose." D. "Exhale completely after compressing the inhaler and then inhale." - ANSWERSB Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration. A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first? A. Accept and document the client's wish to refrain from bathing. B. Offer to give the client a bed bath, avoiding the perineal area. C. Obtain written brochures about menstruation to give to the client. D. Teach the importance of personal hygiene during menstruation with the client. - ANSWERSD Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should receive teaching first, respecting any personal beliefs such as cultural or spiritual values. After client teaching, the client may still choose option A or B. Brochures reinforce the teaching. While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse? A. "How will this affect your present sexual activity?" B. "How active is your current sex life?" C. "How has your sex life changed as you have become older?" D. "Tell me about your sexual needs as an older adult." - ANSWERSA Rationale: Option A offers an open-ended question most relevant to the client's statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement. The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next? A. Document that the client responds to painful stimulus. B. Observe the client's response to verbal stimulation. C. Place the client on seizure precautions for 24 hours. D. Report decorticate posturing to the health care provider - ANSWERS.A Rationale: The client has demonstrated a purposeful response to pain, which should be documented as such. Response to painful stimulus is assessed after response to verbal stimulus, not before. There is no indication for placing the client on seizure precautions. Reporting decorticate posturing to the health care provider is nonpurposeful movement. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL - ANSWERSB Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A. Place the client in a high Fowler position. B. Help the client assume a left side-lying position. C. Measure the tube from the tip of the nose to the umbilicus. D. Instruct the client to swallow after the tube has passed the pharynx. E. Assist the client in extending the neck back so the tube may enter the larynx. - ANSWERSA, D Rationale: (A and D) are the correct steps to follow during nasogastric intubation. Only the unconscious or obtunded client should be placed in a left side-lying position (B). The tube should be measured from the tip of the nose to behind the ear and then from behind the ear to the xiphoid process (C). The neck should only be extended back prior to the tube passing the pharynx and then the client should be instructed to position the neck forward (E). The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly? A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any evidence of weakness is observed. B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back. C. Standing behind his wife, the caregiver provides balance by holding both sides of the gait belt. D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by gently pulling on the gait belt. - ANSWERSB Rationale: His wife is most likely to lean toward the weak side and needs extra support on that side and from the back to prevent falling. Options A, C, and D provide less security for her. Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter? A. Self-care deficit B. Functional incontinence C. Fluid volume deficit D. High risk for infection - ANSWERSD Rationale: Indwelling urinary catheters are a major source of infection. Options A and B are both problems that may require an indwelling catheter. Option C is not affected by an indwelling catheter. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide? A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill. - ANSWERSA Rationale: Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void. When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take? A. Use the normal saline solution once more and then discard. B. Obtain a new sterile syringe to draw up the labeled saline solution. C. Use the saline solution and then relabel the bottle with the current date. D. Discard the saline solution and obtain a new unopened bottle. - ANSWERSD Rationale: Solutions labeled as opened within 24 hours may be used for clean procedures, but only newly opened solutions are considered sterile. This solution is not newly opened and is out of date, so it should be discarded. Options A, B, and C describe incorrect procedures. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client? A. Maintain standard precautions. B. Initiate contact isolation measures. C. Insert an indwelling urinary catheter. D. Instruct client in the use of adult diapers. - ANSWERSA Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing. Option B is not necessary unless the client has an infection. Option C increases the risk of infection. Option D does not reduce the risk of infection. When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take? A. Deflate the cuff completely and immediately reattempt the reading. B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading. C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen. - ANSWERSC Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to return to the extremity so that an accurate reading can be obtained on that extremity a second time. Option A could result in a falsely high reading. Option B reduces circulation, causes pain, and could alter the reading. Option D is not an accurate method of assessing blood pressure. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings. - ANSWERSD Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading. A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit? A. The Patient's Bill of Rights protects clients from malicious intents, so the nurse could lose the case. B. The lawsuit may be settled out of court, but the nurse's license is likely to be revoked. C. There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act. D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved. - ANSWERSC Rationale: The Good Samaritan Act protects health care professionals who practice in good faith and provide reasonable care from malpractice claims, regardless of the client outcome. Although the Patient's Bill of Rights protects clients, this nurse is protected by the Good Samaritan Act. The state Board of Nursing has no reason to revoke a registered nurse's license unless there was evidence that actions taken in the emergency were not done in good faith or that reasonable care was not provided. All four elements of malpractice were not shown. When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent? A. The family can provide the consent required in this situation because the older adult is in no condition to make such decisions. B. Because the client is mentally incompetent, the son has the right to waive informed consent for her. C. The court will allow the health care provider to make the decision to withhold informed consent under therapeutic privilege. D. If informed consent is withheld from a client, health care providers could be found guilty of negligence. - ANSWERSD Rationale: Health care providers may be found guilty of negligence, specifically assault and battery, if they carry out a treatment without the client's consent. The client's condition is stable, so option A is not a valid rationale. Advanced age does not automatically authorize the son to make all decisions for his mother, and there is no evidence that the client is mentally incompetent. Although option C may have been upheld in the past, when paternalistic medical practice was common, today's courts are unlikely to accept it. The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A. Stay with the client while the client is standing. B. Record the findings on the graphic sheet in the chart. C. Keep the blood pressure cuff on the same arm. D. Record changes in the client's pulse rate. - ANSWERSA Rationale: Although all these measures are important, option A is most important because it helps ensure client safety. Option B is necessary but does not have the priority of option A. Options C and D are important measures to ensure accuracy of the recording but are of less importance than providing client safety. A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement? A. Encourage the client to use a nicotine patch. B. Reassure the client that it is almost time for another break. C. Have the client leave the unit with another staff member. D. Review the schedule of outdoor breaks with the client. - ANSWERSD Rationale: The best nursing action is to review the schedule of outdoor breaks and provide concrete information about the schedule. Option A is contraindicated if the client wants to continue smoking. Option B is insufficient to encourage a trusting relationship with the client. Option C is preferential for this client only and is inconsistent with unit rules. Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week? A. White blood cell count B. Albumin C. Calcium D. Sodium - ANSWERSD Rationale: Monitoring serum sodium levels for hyponatremia is indicated during prolonged NG suctioning because of loss of fluids. Changes in levels of option A, B, or C are not typically associated with prolonged NG suctioning. A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? A. Orange juice has vitamin C that deters bacterial growth. B. Apple juice is the most useful in acidifying the urine. C. Cranberry juice stops pathogens' adherence to the bladder. D. Grapefruit juice increases absorption of most antibiotics. - ANSWERSC Rationale: Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs. The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document? A. 14 B. 16 C. 17 D. 28 - ANSWERSB Rationale: The most accurate respiratory rate is the second count obtained by the nurse, which was not interrupted by coughing. Because it was counted for 30 seconds, the rate should be doubled. Options A, C, and D are inaccurate recordings. The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client? A. "Monitoring Your Blood Pressure at Home" B. "Smoking Cessation as a Lifelong Commitment" C. "Decreasing Cholesterol Levels Through Diet" D. "Stress Management for a Healthier You" - ANSWERSC Rationale: A health promotion brochure about decreasing cholesterol is most important to provide this client, because the most significant risk factor contributing to development of arteriosclerosis is excess dietary fat, particularly saturated fat and cholesterol. Option A does not address the underlying causes of arteriosclerosis. Options B and D are also important factors for reversing arteriosclerosis but are not as important as lowering cholesterol. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first? A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client [Show Less]
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HESI FUNDAMENTAL
a 35 year old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to ... [Show More] go home and die. What intervention should the nurse initiate? A. evaluate the client's mental status for competence to refuse treatment B. review the client's medical record for an advance directive C. determine if a DNR prescription has been obtained D. document that the client is being discharged against medical advice - ANSWERSA. evaluate the client's mental status for competence to refuse treatment A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicated the client's protein status for the longest length of time. A. Urine urea B. transferrin C. prealbumin D. serum albumin - ANSWERSD. serum albumin What client statement indicates to the nurse that the client requires assistance with bathing? A. "I only bathe every other day" B. "I left my eyeglasses at home" C. "I don't understand why I'm so weak and tired" D. "I wasn't able to pack a bag before I left for the hospital" - ANSWERSC. "I don't understand why I'm so weak and tired" How should a nurse handle linens that are soiled with incontinent feces? A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room D. place an isolation hamper in the client's room and discard the linens in it - ANSWERSD. place an isolation hamper in the client's room and discard the linens in it When caring for an immobile client, what nursing diagnosis has the highest priority? A. altered tissue perfusion B. impaired gas exchange C. risk for fluid volume deficit D. risk for impaired skin integrity - ANSWERSB. impaired gas exchange The nurse assess an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is the most important for the nurse to implement? A. encourage additional additional fluid intake B. provide the client with an additional blanket C. turn the patient Q2 D. administer a PRN anti hypertensive prescription - ANSWERSC. turn the patient Q2 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 cane. Which assessment finding has the greatest implications for this client's case? A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago B. the client tells the nurse that she does not have much of an appetite today C. the husband, who is the caregiver, begins to weep when you ask how he is doing D. the nurse notes that there are numerous scatter rubs throughout the house - ANSWERSD. the nurse notes that there are numerous scatter rubs throughout the house The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. stage 1 pressure sore draining sero-anguineous drainage B. one-inch pressure sore draining serous fluid C. pressure sore draining serous fluid D. pressure sore on heel with a small amount of purulent drainage - ANSWERSB. one-inch pressure sore draining serous fluid A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 800 B. 0800, 1200, 1600, 2000 C. every other day at 0800 D. 0800, 1200, 1600, 2000, 0000, 0400 - ANSWERSB. 0800, 1200, 1600, 2000 The nurse working in the emergency department is assessing four client's ability to tolerate pain. Which client is likely to tolerate a higher level of pain. A. A 23-year-old woman who sprained her knee while biking B. a 55-year-old woman who has had moderate low back pain for three months C. A 10-year-old who was burned by a camp fire earlier today D. A 70 year-old who has a postoperative infection from a surgery one week ago - ANSWERSB. a 55-year-old woman who has had moderate low back pain for three months A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, " will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? a. "It won't hurt because you're such a big boy" b. "It may hurt a little because of the incision made in your throat" c. "It won't hurt because we put you to sleep" d. "It may hurt but we'll give you medicine to help you feel better" - ANSWERSd. "It may hurt but we'll give you medicine to help you feel better" A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been non compliant with the diet, based on which report from the 24-hour dietary recall? (select all that apply) A. bedtime snack of crackers and milk B. breakfast of eggs, bacon, toast, and coffee C. lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee D. dinner of vegetable lasagna, tossed salad, sherbet, and iced tea E. snack of potato chips, and diet soda - ANSWERSA, B, C & E 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 a chronic venous insufficiency? A. check capillary refill of toes on lower extremity with Unna's paste boot B. apply dressing to a wound area before applying the Unna's paste boot C. remove the Unna's paste boot Q8H to assess wound healing D. wrap the leg from the knee down towards to foot - ANSWERSA. check capillary refill of toes on lower extremity with Unna's paste boot A male client has a nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for the client. A. Reassurance the client that his faith will be regained with time and support B. consult with the staff chaplain and ask that the chaplain visit with the client C. use reflective listening techniques when the client expresses spiritual doubts D. use distraction techniques during times of spiritual stress and crisis - ANSWERSC. use reflective listening techniques when the client expresses spiritual doubts A client has a nursing diagnosis of "Spiritual distress related to loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. instruct the client's family to focus on positive aspect of the client's life B. assist and support the client in establishing short-term goals C. encourage the client to make future plans, even if they are unrealistic D. help the client to accept the final stage of life - ANSWERSB. assist and support the client in establishing short-term goals A female nurse who sometimes tries to save time by putting medications in her uniform to clients, confides that after arriving home she found hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? a. accused of unprofessional conduct b. accused of diversion c. reported for stealing d. reported for a HIPAA violation - ANSWERSb. accused of diversion A signed consent form indicated a client should have an EKG, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plantiff because these events represent which infraction? A. An unintentional tort because the client benefited from having the myelogram B. Assault and battery with deliberate intent to deviate from the consent form C. A quisi-intentional because a similar mistake can happen to anyone D. failure to respect client autonomy to choose based on international tort law - ANSWERSB. Assault and battery with deliberate intent to deviate from the consent form A 75 year old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, starting the death is inevitable, but the client is discontinues and will not sign a DNR directive. A. review the client's most recent laboratory reports B. determine who is legally empowered to make decisions C. refer the client and family members for hospice D. notify the patient ethics committee of the client situation - ANSWERSB. determine who is legally empowered to make decisions The change nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. review the steps in the procedural manual B. refuse to perform the task that is beyond the nurse's experience C. ask another nurse to assist while implementing the procedure D. follow the agency's policy and procedure - ANSWERSB. refuse to perform the task that is beyond the nurse's experience Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the health care provider. After consultation with the health care provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Document the events that occurred in the nurse's notes B. notify the charge nurse that a medication error occurred C. submit a medication valence report to the supervisor D. discard the original medication administration record - ANSWERSA. Document the events that occurred in the nurse's notes On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. provide warm prune juice before the client goes to bed at night B. teach the client to splint the incision while walking to the bathroom C. remind the client to turn every two hours while lying in bed D. administer an analgesic before the client attempts to defecate - ANSWERSA. provide warm prune juice before the client goes to bed at night The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. fluid volume imbalance B. impaired skin integrity C. caregiver role strain D. disturbed sleep pattern - ANSWERSA. fluid volume imbalance A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical". What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students B. Ask the client if permission was obtained from the client C. explain the records are hospital property and may not be removed D. notify the student's clinical instructor of the situation - ANSWERSC. explain the records are hospital property and may not be removed After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. read the consent form to the client before witnessing the client's signature B. determine if the client's spouse is willing to sign the consent form C. notify the surgeon that the consent form has not been signed D. administer an opioid antagonist prior to obtaining the client's signature - ANSWERSC. notify the surgeon that the consent form has not been signed A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Instruct the patient to remain on bedrest until the healthcare provider is contracted B. encourage the client to take several slow, deep breaths while ambulating C. advise the client to sit on the side of the bed for a few minutes before standing again D. help the client to remain standing by the bedside until the dizziness is relieved - ANSWERSC. advise the client to sit on the side of the bed for a few minutes before standing again The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20-pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. ask another staff member for assistance B. request that supplies are delivered in smaller containers C. push the box against the wall to provide support while lifting D. bend at the knees when lifting heavy objects - ANSWERSD. bend at the knees when lifting heavy objects An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? A. apply flannel pajamas to provide warmth B. administer a PRN dose of ibuprofen C. Drape the sheets over the foot board of the bed D. perform ROM exercises in a warm tub - ANSWERSC. Drape the sheets over the foot board of the bed A client is admitted to the hospital with intractable pain. When instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. a client's pain will be difficult to manage, since the cause is still unknown B. take measures to promote as much comfort as possible C. report any signs of drug addiction to the nurse immediately D. wait until the client's pain is gone before assisting with personal care - ANSWERSB. take measures to promote as much comfort as possible A male client arrives at the out patient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the health care provider. What action should the nurse implement? A. verify the client's consent with the health care provider B. document that the client has given consent for the needle aspiration C. witness the client's signature on the consent form D. notify the healthcare provider that the client is ready for the procedure - ANSWERSC. witness the client's signature on the consent form In assessing a client's femoral pulse, the nurse must use deep pulsation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. document the presence and volume of the pulse palpated B. elevate the head of the bed and attempt to palpate the site again C. record the presence of pitting edema in the inguinal area D. use a thigh cuff to measure the blood pressure in the leg - ANSWERSA. document the presence and volume of the pulse palpated A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement? A. insert the suppository very gently being careful not to further injure the rectal bleeding. What action should the nurse implement? A. insert the suppository very gently being careful not to further the rectal mucosa B. withhold the administration of the suppository until contacting the healthcare provider C. administer the medication as scheduled after assessing the client's vital signs D. Ask the pharmacist to send an alternate from the prescribed medication to the unit - ANSWERSB. withhold the administration of the suppository until contacting the healthcare provider The nurse is preparing to irrigate a client's indwelling catheter using an open technique. What action should the nurse take after applying gloves? A. Draw up the irrigating solution into the syringe B. use aseptic technique to instill the irrigating solution C. empty the client's urinary catheter D. secure the client's catheter to the drainage tubing - ANSWERSA. Draw up the irrigating solution into the syringe When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. there are no dependent loops in the drainage tubing B. the clamp on the urinary drainage bag is open C. the drainage tubing is secured over the siderail D. the urinary drainage bag is attached to the bed frame - ANSWERSB. the clamp on the urinary drainage bag is open While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? [Show Less]
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