HESI FUNDAMENTALS EXAM- 2020 REVISION GUIDE
1. A client at an outpatient clinic submits a clean- catch midstream urine specimen for a routine
... [Show More] urinalysis. In later review of the client's medical record, which data indicates to the nurse that the specimen collection should be repeated?
A. The urine specimen shows multiple organisms in low colony counts.
B. The client reported eating a meal before voiding the urine specimen
C. There was a total of 30 ml of urine voided into the specimen cup
D. The medical record indicates the client is allergic to most antibiotics
2. When assessing a client who starts to wheeze which related data should the nurse obtain?
A. Precipitating factors
B. Body Temperature
C. Presence of radiation
D. Heart sounds
3. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in this client’s teaching?
A. “Administer the medication directly on the cornea.”
B. “Wash your hands after each administration of eye drops.” C. “Do not allow the dropper bottle to touch the eye.”
D. “Squeeze your eye closed after administering the drops.”
4. The nurse observes that a male client on a clear liquid diet has a cup of coffee on his breakfast tray. What action should the nurse implement?
A. Consult with the dietician to learn if the client is allowed to drink coffee
B. Determine which member of the nursing staff brought the cup of coffee to the client
C. Remind the client that no milk, or creamer can be added to the coffee.
D. Remove the coffee from the tray, advising the client that it is not included in the diet.
5. 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. Determine if the expected outcomes were realistic
B. Modify the nursing interventions to achieve the client’s goals C. Obtain current client data to compare with expected outcomes D. Review related professional standards of care.
6. The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. In designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
A. Return demonstration
B. Journaling
C. Analogies D. Role playing
7. The nurse observes the skin over a client's greater trochanter as seen in the picture. What actions should the nurse implement? (select all that apply)
A. Remove the eschar before applying and securing a hydrocolliod
B. Prepare to implement a pressure redistribution mattress
C. Obtain a specimen of the site for culture and sensitivity
D. Instruct the Unlicensed assistive personnel to frequently offer oral fluids
E. Explain to the client that the wound needs debridement
8. The nurse has removed the barbiturate capsule from the unit dose wrapper to administer to a male client. The client decides he wants to watch a television program and requests not to take the medication. Which action should the nurse implement?
A. Credit the medication back and put in the client’s medication box
B. Keep the medication and see if the client will want to take it later.
C. Have another nurse watch disposal of the medication into disposal container
D. Explain that since the medication is a controlled substance it must be taken.
9. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personal (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply).
A. Shuffling gait. B.Diminished visual acuity.
C. Syncope when bending. D. hands tremors.
E.Urinary incontinence
10. The charge nurse observes a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound?
A. Starts at the wound site and moves outward using circular motions.
B. Cleanses from the outer area of the wound toward the center
C. Uses a sterile swab to go over the wound site twice.
D. Scrubs wound vigorously for at least two minutes
11. The nurse is evaluating the fluid balance of the client who was admitted yesterday with dehydration and who has been receiving iv fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating.
A. Serum haematocrit.
B. Urine specific gravity.
C. Pulse Rate.
D. Urinary output.
12. 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?
a. Explain the respiratory problems that can occur with morphine use.
b. Teach family how to evaluate the effectiveness of analgesics.
c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump.
d. Provide client with a schedule of around-the-clock prescribed analgesic use.
13. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next?
a. Position suction in the trachea.
b. Apply nasal cannula oxygen.
c. Insert a tongue blade.
d. Observe the suction secretion.
14. 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 non-verbal 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.
15. 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. Determine the client’s activities and feelings prior to the BP measurement. b. Retake the Client's blood pressure in the opposite arm
c. Assign the unlicensed assistive personnel to recheck the BP in an hour. (not the answer because it should be rechecked sooner)
d. Ask another nurse to assist in assessing for an apical-radial pulse deficit.
e. Immediately take two more readings on the same arm.
16. A male Native American presents to the clinic with complaints of frequent abdominal cramping and Nausea. He states that he has chronic constipation and has not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is most important for the nurse to implement.
a. Access for the presence of an impaction.
b. Evaluate stool sample for the presence of blood.
c. Obtain list of prescribed home medications. d. Determine what home remedies where used.
17. The Practice Nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the Charge Nurse (CN) observes the PN, what actions should the charge nurse take?
a. Confirm that PN is ready to assist with the planned procedure.
b. Obtain all new supplies and directly assist with the procedure.
c. Remove the contaminated package of sponges from the table.
d. Instruct the PN to remove the gloves that are now contaminated.
18. 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 leg. What action should the nurse implement?
a. Encourage the client to take short walks around the block.
b. Advice the client to dangle his feet during meals and before bedtime. c. Ensure the clients to flex both of his feet, several times a day.
d. Explain the need to keep the head of the bed elevated.
19. A male client with a recent diagnosis of terminal cancer, tells his nurse that he wishes to die naturally. The client states that he’s tired of fighting this illness and is only continuing treatment because of his family’s wishes. What actions should the nurse take?
a. Request a consultation for a psychologist to talk with the client.
b. Call a clergy to discuss end-of-life decisions with the client. c. Determine if he wants to stop radiation and chemotherapy.
d. Arrange a meeting with the client, his family and the healthcare provider.
20. A male client who had emergency gallbladder surgery yesterday is getting ready for discharge. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home?
a. Have the client demonstrate prescribed wound care.
b. Provide written instructions in the client’s native language.
c. Have an interpreter repeat the wound care instructions.
d. After each instruction, ask the client if he understands.
21. 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?
a. Access for side effects of the medication.
b. Document the client’s responses.
c. complete a medication error report.
d. Determine if the pain was relieved.
22. The nurse is evaluating a client who is admitted to an adult medical unit, and notes that a client’s urine output has been 70 ml/hr. Which action should the nurse implement?
a. Recommend drinking cranberry juice with meals.
b. Encourage the client to drink more fluids.
c. Document the client’s urinary output every hour. (NORMAL RANGE)
d. Notify the healthcare provider immediately.
23. A client is admitted with Pneumonia and has a recent history of Methicilline-resistance Staphylococcus aureus (MRSA). The Client is placed in isolation while caring for the client, which client should the nurse place in a designated bio-hazard bag before it is removed from the room?
a. A sputum specimen. (BODILY FLUIDS=BIOHAZARD)
b. Paper mask and gown.
c. The nurse’s stethoscope.
d. Bed linens.
24. A client is receiving Ketorolac (Toradol) IM 45mg IM every 6 hours for post operative pain. The available 2ml vile is labeled, Toradol 30mg / ML. How many ML should the nurse administer? (enter numerical value only, If rounding is required round to the nearest Tenths).
25. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first.
a. blood pressure.
b. Respiratory rate. (Cyanosis caused by low oxygen levels in the RBCs)
c. Pulse Rate.
d. Temperature.
26. An older male client returns to the clinic for chronic pain management after taking morphine sulphate (MS contin) 25mg every 12hrs. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement?
a. Explain the risk of drug addiction from long term pain medication.
b. Tell the client to continue taking the MS contin with severe pain.
c. Instruct the client to take the MS Contin every 12 hours as prescribed.
d. Teach the client alternative ways to manage his chronic pain.
27. A client is admitted with complaints of shortness of breath (Dyspnea) on exertion, and chest pressure The healthcare provider prescribes a medication that is unfamiliar to the nurse.
When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. What actions should the nurse take?
a. Consult pharmacists for those clarification.
b. Verify the prescribed dosage with a healthcare provider.
c. Administer the medication as prescribed.
d. Give the dosage recommended in the drug handbook.
28. 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 the nurse contact?
a. The client’s youngest son was identified by family members as the family’s spokesperson.
b. A daughter-in-law designated as the client’s durable power of attorney (DPOA)
c. The client’s spouse who lives in the independent living unit of the facility.
d. The client's oldest living child, a lawyer who is visiting from out of town.
29. What explanation is best for the nurse to provide a client who asked the purpose of using the log-rolling technique for turning?
a. Working together can decrease the risk of back injury to the nurses.
b. Turning instead of pulling reduces the likelihood of skin damage. c. The technique is intended to maintain straight spinal alignment.
d. Using two or three people increases client’s safety.
30. The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes does the nurse recommend the client wear when ambulating with her husband’s assistance?
a. Slip-on rubber shower shoes.
b. Tennis shoes with Velcro. (FALL PRECAUTION)
c. Rubber sole slippers.
d. Leather sole loafers.
31. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to
write a “Do Not Resuscitate”(DNR Prescription). What actions should the nurse take?
a. Ensure resuscitation equipment is available.
b. Ask the family to review options with the client.
c. Place a DNR bracelet on the client’s arm.
d. Initiate an ethics committee review of the case.
32. A client newly diagnosed with stage 3 lung cancer becomes angry with the healthcare provider and nursing staff. Which intervention is most important for the nurse to implement?
a. Arrange for the client to meet with another client who has lung cancer.
b. Request a consultation from an oncology social worker.
c. Acknowledge the client’s anger and attempt to address its source. d. Allow the client and family time to be alone.
33. 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”. Which outcome statement is best for the nurse to include in the client’s plan of care?
a. To take analgesic as prescribed. b. To ambulate without discomfort.
c. To show evidence of incision healing.
d. To avoid pain-causing activity.
34. An adult client complains of insomnia and asks the nurse to recommend a sleeping pill.
What reply is best for the nurse to provide?
a. “Have you discussed this with your healthcare provider?”
b. “Zolpidem Tartate (ambien) is used for insomnia.”
c. “Sleeping medication require side effects that require caution” d. “Tell me about your insomnia and how you treat it”
35. 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 “2mg / ml” How many ml should the nurse administer?(enter numerical value only, If rounding is required round to the nearest Tenths). [0.75 X]
36. 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. Total calcium 9.2 mg/dl (2.3 mmol/L)
b. Potassium 3.1 mEq/L (3.1 mmol/L) (LOW)
c. Chloride 98 mEq/L (98 mmol/L)
d. Sodium 142mEq/L (142 mmol/L)
37. 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).
a. Solid with red streaks. b. Brown liquid.
c. Multiple hard pellets.
d. Formed but soft. e. Tarry appearance.
38. During the admission assessment of a terminally ill male client, The client states that he is an agnostic. What is the best nursing action in response to this statement.
a. Provide information about the hours and location of the chapel. b. Document the statement in the client’s spiritual assessment.
c. Offer to contact a spiritual advisor of the client’s choice.
d. Invite the client to a healing service for people of all religions.
39. A client is discharged to a long-term care facility. With an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk of infection related to the catheter.
a. Secure the drainage bag at bladder level during transport. b. Flush the catheter daily with sterile saline solution.
c. Administer PRN Antipyretic if a fever develops.
d. Encourage increased intake of oral fluids.
40. The community healthcare nurse is making a home visit when the client, who is sitting at the kitchen table begins to have a seizure. What action should the nurse take first?
a. Assist the client to the floor.
b. Access the client’s vital signs.
c. Call 911 for an ambulance.
d. Remove nearby furniture.
41. The nurse prefers to implement a prescription for oxygen at 4 L/minute per nasal cannula. For a client with an oxygen saturation of 90%.
The nurse observes the flow meter set up provided by the respiratory therapist, as seen in the picture.
What action should the nurse take next?
a. Adjust the flow rate to 4 L/minute
b. Attach oxygen tubing to the flow meter.
c. Drain the water out of the humidifier.
d. Document the presence of breath sounds.
43. The nurse observes the unlicensed assistive personnel (UAP) securing a client’s wrist restraints to the bed side rails.
Which action is most important for the nurse to implement?
a. Initiate the facility’s restraint flow sheet.
b. Demonstrate proper securing of the restraint.
c. Ensure that the restraints are not too tight.
d. Complete an adverse occurrence/incidence report.
44. A nurse administers an opioid analgesic to a post operative client who also has severe obstructive sleep apnea (OSA).
What intervention is most important for the nurse to implement before leaving the client alone?
a. Apply the client’s positive airway pressure device.
b. Lift and lock the side rails in place.
c. Remove dentures or other oral appliances.
d. Elevate the head of the bed to 45 degree angle (MORE RISK FOR RESPIRATORY COMPLICATIONS)
45. A policy requiring the removal of acrylic 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.
a. Number of staff induced injury
b. Client satisfaction survey
c. Health care-associated infection rate.
d. Rate of needle-stick injuries by nurse.
46. 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?
a. Complete the intermittent suction of the nasopharynx.
b. Reposition the pulse oximeter clip to obtain a new reading.
c. Stop suctioning until the pulse oximeter reading is above 95%. d. Apply an oxygen mask over the client’s nose and mouth
47. The nurse is preparing a teaching plan for a client with low back pain. Which sleeping position should be included in the teaching?
a. Side-lying with hips and knees flexed.
b. Supine with hips and knees and neutral straight position.
c. Head of bed elevated to 30 degrees.
d. Prone with a pillow under the lower abdomen.
48. What self-care outcome is best for the nurse to use in evaluating a client’s recovery from a stroke that resulted in left-sided hemiparesis?
a. Self-care needs to be completed by the unlicensed assistive personnel.
b. Participate in self-care to an optimal level of capacity.
c. Promote independence by allowing clients to perform all self-care activities.
d. Client verbalizes importance of hygienic practices in the recovery process.
49. It is most important for the nurse to recalculate the braden scale score for a client who has developed which problem.
a. Urinary incontinence.
b. Hypo-active Bowel sound. c. Plus Two ankle Edema.
d. Weakened cough efforts.
50. When performing blood pressure measurement to assess for orthostatic hypotension, Which action should the nurse implement first?
a. Apply the blood pressure cuffs securely.
b. Assist the client to stand at the bedside.
c. Position the client supine for a few minutes.
d. Record the client’s pulse rate and rhythm .
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