HESI
FUNDAMENTALS
EXAM
HESI Fundamentals
TOPTARGET ACADEMICS
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HESI Fundamentals Exam
A policy required the removal of acrylic
... [Show More] nails by all nursing personnel was
implemented 6 months ago. Which assessment measure best determines if the
intended outcome of the policy is being achieved?
(ANS- health care-associated infection rate
The nurse is preparing to assist a newly admitted client with person hygiene
measures. The client... the client's gag reflex. Which action should the nurse
include?
(ANS- place tongue blade on back half of tongue
The nurse explains to an older adult male the procedure for collecting a 24-hr urine
specimen for creatinine clearance.
(ANS- empty the urinal contents into the 24-hr collection container
A 54 yo male client and his wife were informed this morning that he has terminal
cancer. Which nursing intervention is most appropriate for the wife? (ANS- refer
her to support group for family members of those dying of cancer
A client who has a body mass index (BMI) of 30 is requesting information on the
initial approach to a weight loss plan. Which action should the nurse recommend?
(ANS- keep a record of food and drinks consumed daily
The nurse assesses a client who has a nasal cannula delivering oxygen at 2L/min.
To assess for skin damage related to the cannula, which areas should the nurse
observe?
(ANS- top of the ear
around the nostrils over
the checks
The nurse observes an unlicensed assistive personnel (UAP) who is providing a
total bed bath for a confused and lethargic client. The UAP is soaking the clients
foot in a basin of warm water placed on the bed. What action should the nurse
take? (ANS- remind the UAP to dry between the clients toes completely
The nurse in the emergency department observes a colleague viewing the
electronic health record of a client who holds an elected position in the community.
The client is not a part of the colleagues assignment. Which action should the
nurse implement?
(ANS- communicate the colleagues action to the unit. charge nurse
At 0100 on a male clients second postoperative night, the client states he is unable
to sleep and plans to read until feeling sleepy. What action should the nurse
implement?
(ANS- bring the client a prescribed PRN sedative-hypnotic
The nursing staff in the cardiovascular intensive care unit are creating a continuous
quality improvement project on social media that addresses coronary artery
disease. Which action should the nurse implement to protect client privacy?
(ANS- remove identifying information of the clients who participated
A male client with unstable angina needs a cardiac catheterization, so the
healthcare provider explains the risks and benefits of the procedure and then leaves
to set up for the procedure. When the nurse presents the consent form for signature,
the client hesitates and asks how the wires will keep his heart going. Which action
should the nurse take?
(ANS- postpone the procedure until the client understands the risks and benefits
The nurse is teaching a client how to do active range of motion exercises. To
exercise the hinge joints, which action should the nurse instruct the client to
perform?
(ANS- bend the arm by flexing the ulnar to the humerus
A postoperative client has three different PRN analgesics prescribed for different
levels of pain. The nurse inadvertently administers a dose that is not within the
prescribed parameters. What actions should the nurse take first?
(ANS- access for side effects of the medication
When assessing a male client, the nurse finds that he is fatigued, and is
experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on
these findings, the nurse plans to check the clients laboratory values to validate the
existence of which? (ANS- hypokalemia
A female client's significant other has been at her bedside providing reassurances
and support for the past 3days, as desired by the client. The client's estranged
husband arrives and demands that the significant other not be allowed to visit or be
given condition updates. Which intervention should the nurse implement? (ANSrequest a consultation with the ethics committee for solution of the situation
When measuring vital signs, the nurse observes that a client is using accessory
neck muscles during respirations. What follow-up action should the nurse take
first?
(ANS- check for neck vein distention
To avoid nerve injury, what location should the nurse select to administer a 3 mL
IM injection?
(ANS- outer upper quadrant of the buttocks
Which instruction should the nurse include in the discharge teaching plan for an
adult client with hypernatremia?
(ANS- review food labels for sodium content
While changing a client's post operative dressing, the nurse observes a red and
swollen wound with a moderate amount of yellow and green drainage and a foul
odor. Given there is a positive MRSA, which is the most important action for the
nurse to take?
(ANS- initiate contact precautions
To prepare a client for the potential side effects of a newly prescribed medication,
what action should the nurse implement?
(ANS- assess the client for health alterations that may be impacted by the effects
of the medication
A client is 2 days post-op from a thoracic surgery and is complaining of incisional
pain. The client last received pain medication 2 hours ago. He is rating his pain a 5
on a 1-10 scale. After calling the provider, what is the nurse's next action? (ANSinstruct the client to use guided imageryand slow rhythmic breathing
A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The
pharmacy provides 20 mg tablets. How many tablets should the client receive each
day? [Enter numeric value only]
(ANS- 4 tabs
An older adult male client is admitted to the medical unit following a fall at home.
When undressing him, the nurse notes that he is wearing an adult diaper and skin
breakdown is obvious over his sacral area. What action should the nurse
implement first?
(ANS- determine the size and depth of skin breakdown over the sacral area
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?
(ANS- the nurse has limited ability to observe nonverbal communication while
entering the assessment electronically
A female client with chronic back pain has been taking muscle relaxants and
analgesics to manage the discomfort, but is now experiencing an acute episode of
pain that is not relieved by this medication regime. The client tells the nurse that
she does not want to have back surgery for a herniated intervertebral disk, and
reports that she has found acupuncture effective in resolving past acute episodes.
Which response is best for the nurse to provide?
(ANS- acupuncture is a complementary therapy that is often effective for
management of pain
The nurse is providing wound care to a client with stage 3 pressure ulcer that has a
large amount of eschar. The wound care prescription states "clean the wound and
then apply collagenase." Collagenase is a debriding agent. The prescription does
not specify a cleaning method. Which technique should the nurse cleanse the
pressure ulcer?
(ANS- irrigate the wound with sterile normal saline
A client is admitted with a fever of unknown origin. To assess fever patterns, which
intervention should the nurse implement?
(ANS- measure temperature at regular intervals
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first?
(ANS- position the client supine for a few minutes
.The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an
automated dispensing system, for a client who is receiving hydromorphone 3 mg
IM 6 hours PRN severe pain. How many mL should the nurse administer to the
client? (Enter the numerical value only. If rounding is required , round to the
nearest tenth)
(ANS- 0.8 ml
The unlicensed assistive personnel (UAP) describes the appearance of the bowel
movement of several clients. Which description warrants additional follow up by
the nurse? (select all that applies). (ANS- solid with streaks brown liquid
multiple hard pellets tarry appearance
A female UAP is assigned to take the vital signs of a client with pertussis for whom
droplet precautions have been implemented. The UAP requests a change in
assignment...she has not yet been fitted for a particulate filter mask.Which action
should the nurse take?
(ANS- send the UAP to be fitted for a particulate filter mask immediately so she
can provide care to this client
In-home hospice care is arranged for a client with stage 4 lung cancer. While the
palliative nurse is arranging for discharge, the client verbalizes concerns about
pain. What action should the nurse implement?
(ANS- provide client with a schedule of around-the-clock prescribed analgesic use
What assessment finding places a client at risk for problems associated with
impaired skin integrity? (ANS- capillary refill 5 seconds
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?
(ANS- determine if the expected outcomes were realistic
The nurse attaches a pulse oximeter to a client's fingers and obtains an oxygen
saturation reading of 91%. Which assessment finding most likely contributes to
this reading?
(ANS- 2+ edema of fingers and hands
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 the client. When
the family leaves, what action should the nurse take first?
(ANS- reassess the client to determine the need for continuing restraints
The nurse is discharging an adult woman who was hospitalized for 6 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?
(ANS- instruct the client to repeat the medication plan
What instruction should the nurse provide for an UAP caring for a client with
MRSA who has a prescription for contact precautions?
(ANS- don a gown and gloves when entering the return
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? (ANScomplete the intermittent suction of the nasopharynx
UAP has lowered the head of the bed to change the lines for a client who is
bedless. Which observation...most immediate intervention by the nurse? (ANSpurulent drainage is present around the insertion site of the feeding tube
A male client presents to the clinics stating that he has a high stress job and is
having difficulty falling asleep at night. .The client reports having a constant
headache and is seeking medication to help the sleep. Which intervention should
the nurse implement?
(ANS- teach coping strategies to use wheen feeling stressed
he nurse is teaching a client about use of the syringes and needles for home
administration of medications. Which action by the client indicates an
understanding of standard precaution?
(ANS- wash hands before handling the needle and syringe
The nurse observes an UAP positioning a newly admitted client who has a seizure
disorder. The client is supine and the UAP is placing soft pillows along the side
rails. Which action should the nurse implement?
(ANS- assume responsibility for placing the pillows while the UAP completes
another task
A cerebrovascular accident is placed on a ventilator. The client's daughter arrives
with a durable power of attorney, and a living will that indicates the...extraordinary
life saving measures. What action should the nurse take?
(ANS- notify the healthcare provider
Earlier this morning, an elderly Hispanic female was discharged to a LTC facility.
The family members are now gathered in the hallway outside her room. What is
the best action?
(ANS- provide space and privacy for the family to share their concerns about the
clients discharge
A client with rheumatoid arthritis is experiencing chronic pain in both hands and
wrists. Which information about the client is most important for the nurse to obtain
when planning care?
(ANS- the ability to perform ADLs
A male Native American presents to the clinic with complaints of frequent
abdominal cramping and nausea. He states that the 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?
(ANS- determine what home remedies were used
Which assessment data reflects the need for the nurses to include the problem,
"Risk for falls" in a client's plan of care?
(ANS- opioid analgesic received one hour ago
The nurse receives a report that a client with an indwelling urinary catheter has an
output of 150 mL, for the previous 6 hour shift. Which intervention should the
nurse implement first?
(ANS- review the intake and output record
The nurse is conducting an initial admission assessment for a woman who is
Mexican-American and who is scheduled to deliver a baby by C-section in the next
24 hours. What should the nurse include in the assessment?
(ANS- rely on cultural norms as the basis for providing nursing care for this client
During the admission assessment of a terminally ill male client that he is an
agnostic. What is the best nursing action in response to this statement? (ANSdocument the statement of clients spirtiual assessment
The nurse is reviewing the signed operative consent with a client who is admitted
for the removal of a lipoma on the left leg. The client states that the permit should
include...
(ANS- inform the surgeon about the clients concern
The nurse plans to assist a male client out of bed for the first time since his surgery
yesterday. His wife objects and tells the nurse to get out of the room because her
husband is too ill to get out of bed.
(ANS- check the clients blood pressure and pulse deficit
When entering the room of an adult male, the nurse finds that the client is very
anxious. Before providing care, what action should the nurse take
(ANS- re-assess the client situation [Show Less]