HESI FUNDAMENTALS EXIT EXAM
A nurse is teaching staff members about the legal terminology used in child abuse. What definition
of battery should the
... [Show More] nurse 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.
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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.
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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.
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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.
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6. 130049055
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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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.
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