HESI Fundamentals Version |Best Rated Questions and Answers
1. UAP has lowered the head of the bed to change the lines for a client who is bedless.
... [Show More] Which observation. . . most immediate intervention by the nurse?
A. A feeding is infusing at 40 mL/hr through an enteral feeding tube
B. The urine meter attached to the urinary drainage bag is completely full
C. There is a large dependent loop in the client’s urinary drainage tubing
D. Purulent drainage is present around the insertion site of the feeding tube
2. 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?
A. Determine the client’s sleep and activity pattern
B. Obtain prescription for client to take when stressed
C. Refer client for a sleep study and neurological follow-up
D. Teach coping strategies to use when feeling stressed
3. The 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?
A. Remove needle before discarding used syringes
B. Wear gloves to dispose of the needle and syringe
C. Done a face mask before administering the medication
D. Washes hands before handling the needle and syringe
4. 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?
A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
B. Ensure that the UAP has placed pillows effectively to protect the client
C. Ask the UAP to use some pillows to prop the client in a side-lying position
D. Assume responsibility for placing the pillows while the UAP complete another task
5. 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?
A. Refer to the risk manager
B. Notify the healthcare provider
C. Discontinue the ventilator
D. Review the medical record
6. 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?
A. Ask the family to wait in the cafeteria when the next of kin makes the necessary arrangements
B. Provide space and privacy for the family to share their concerns about the client’s discharge
C. Ask the social worker to encourage the family to clear the hallway
D. Explain to the family the client’s need for privacy so that she can make independent decisions
7. 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?
A. Amount of support provided by family members
B. Measurement of pain using a scale of 0 to 10
C. The ability to perform ADLs
D. Nonverbal behaviors exhibited when pain occurs
8. 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?
A. Evaluate the stool samples for presence of blood
B. Assess for the presence of an impaction
C. Determine what home remedies were used
D. Obtain list of prescribed home medication
9. Which assessment data reflects the need for the nurses to include the problem, “Risk for falls” in a client’s plan of care?
A. Recent serum hemoglobin level of 16g/dL
B. Opioid analgesic received one hour ago
C. Stooped posture with a steady gait
D. Expressed feelings of depression
10. What assessment finding places a client at risk for problems associated with impaired skin integrity?
A. Scattered macula of the face [Show Less]