HESI RN Fundamentals
HESI RN Fundamentals
1. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing
... [Show More] a walker in front of her. What action should the nurse take in response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
2. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse administer?
(Round to the nearest tenth.)
1.5mg
3. 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) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client’s nose and mouth.
4. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a “do not resuscitate” (DNR) prescription.
C) Set up a family conference to discuss the client’s.
D) Consult the palliative care team about client’s care.
5. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching?
A) “Do not allow the dropper bottle to touch the eye.”
B) “Administer the medication directly on the cornea.”
C) “Squeeze your eye closed after administering the drops.”
D) “Wash your hands after each administration of eye drops.”
6. When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
7. The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personnel? (UAP) to provide routine foot care and file the client’s toenails? Select all that apply.)
A) syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
8. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client’s risk for infection related to the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
9. To assess the quality of an adult client’s pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
10. A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide?
A) “That’s correct, you do not have long to live”
B) “Would you like me to call your minister?”
C) “Don't give up, you still have chemotherapy to try.”
D) “Yes, your condition is serious.”
11. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client’s pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside.
12. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next?
A. Raise the bed to a comfortable working level.
B. Bend the client's knee.
C. Move the knee toward the chest as far as it will go.
D. Cradle the client's heel. Correct
13. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
A. Continue gabapentin.
B. Discontinue ibuprofen.
C. Add aspirin to the protocol.
D. Add oral methadone to the protocol.
14. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?
A. Empty the client's urinary drainage bag.
B. Draw up the irrigating solution into the syringe.
C. Secure the client's catheter to the drainage tubing.
D. Use aseptic technique to instill the irrigating solution.
15. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions?
A. Removing the empty food tray from a client with a urinary catheter.
B. Washing and combing the hair of a client with a fractured leg in traction.
C. Administering oral medications to a cooperative client with a wound infection.
D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct
16. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?
A. Maintain in a lateral position using protective wrist and vest devices.
B. Position prone with a small pillow below the diaphragm.
C. Raise the head and knee gatch when lying in a supine position.
D. Transfer into a wheelchair close to the nurse's station for observation.
17. At 0100 on a male client’s second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
A. Leave the room and close the door to the client’s room
B. Assess the appearance of the client’s surgical dressing
C. Bring the client a prescribed PRN sedative-hypnotic
D. Discuss symptoms of sleep deprivation with the client
18. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
A. Remove identifying information of the clients who participated
B. Recall that authored content may be legally discoverable
C. Share material from credible, peer reviewed sources only
D. Respect all copyright laws when adding website content
19. 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?
A. Answer the client’s specific questions with a short understandable explanation
B. Postpone the procedure until the client understands the risks and benefits
C. Call the client’s next of kin and ask them to provide verbal consent
D. Page the healthcare provider to return and provide additional explanation
20. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?
A. Tilt the pelvis forwards and backwards
B. bend the arm by flexing the ulnar to the humerus
C. Turn the head to the right and left
D. Extend the arm at the ide and rotate in circles
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. When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which?
A. Hyperphosphatemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hypokalemia
23. 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?
A. Obtain a perception from the healthcare provider regarding visitation privileges
B. Request a consultation with the ethics committee for resolution of the situation
C. Encourage the client to speak with her husband regarding his disruptive behavior
D. Communicate the client’s wishes to all members of the multidisciplinary team
24. 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?
A. Determine pulse pressure
B. Auscultate heart sounds
C. Measure oxygen saturation
D. Check for neck vein distention
25. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection?
A. Ventrogluteal
B. outer upper quadrant of the buttock
C. Two inches below the acromion process
D. Vastus lateralis
26. Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia?
A. Monitor daily urine output volume
B. Drink plenty of water whenever thirsty
C. Use salt tablets for sodium content
D. Review food labels for sodium content
27. 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?
A. Force oral fluids
B. Request a nutrition consult
C. Initiate contact precautions
D. Limit visitors to immediate family only
28. 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 nonverbal 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.
29. 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 nurse contact?
A) The client’s oldest living child, a lawyer, who is visiting from out of town.
B) A daughter -in-law designated as the client’s Durable Power of Attorney (DPOA).
C) The client’s youngest son, identified by family members as the family spokesperson.
D) The client’s spouse who lives in the independent living unit of the facility.
30. A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions?
A) Change coccyx dressing, perform tracheostomy care, restart the IV.
B) Perform tracheostomy care, change coccyx dressing, restart the IV.
C) Restart the IV, perform tracheotomy care, change coccyx dressing.
D) Change coccyx dressing, restart the IV, perform tracheostomy care.
31. What self-care outcome is best for the nurse to use in evaluating a client’s recovery form a stroke that resulted in left-sided hemiparesis?
A) Promote independence by allowing client to perform all self-care activities.
B) Participates in self-care to optimal level of capacity.
C) Client verbalizes importance of hygienic practices in the recovery process.
D) Self-care needs to be completed by the unlicensed assistive personnel.
32. A female client’s significant other has been at her bedside providing reassurance and support for past 3 days, as desired by the client. The client’s estranged husband arrives and demands the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
A) Communicate the client’s wishes tall members of the multidisciplinary team.
B) Encourage the client to speak with her husband regarding his disruptive behavior.
C) Request a consultation with the ethics committee for resolution of the situation.
D) Obtain a prescription from the healthcare provider regarding visitation privilages.
33. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement?
A) Decrease the flow rate to 1 L/minute.
B) Discontinue the use of the nasal cannula.
C) Apply lubricant to the cannula tubing.
D) Place padding around the cannula tubing.
34. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement?
A) Ask a Spanish speaking staff member to talk with the family.
B) Use a Spanish translation reference to interview the family.
C) Close the door to client’s room to provide family privacy.
D) Sit quietly with the family to offer comfort and support.
35. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented?
A) Apply a hydro gel (Duaderm) dressing
B) Increase the frequency of the dressing changes.
C) Replace the gauze with transparent dressing.
D) Leave the dressing off until consulting with the healthcare provider.
36. Which client care requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions?
A. Removing the empty food tray from a client with a urinary catheter.
B. Washing and combing the hair of a client with a fractured leg in traction.
C. Administering oral medications to a cooperative client with a wound infection.
D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
37. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile?
A. Maintain in a lateral position using protective wrist and vest devices.
B. Position prone with a small pillow below the diaphragm.
C. Raise the head and knee gatch when lying in a supine position.
D. Transfer into a wheelchair close to the nurse's station for observation.
38. 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 chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing.
39. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first?
A. Check for a blood return.
B. Reposition the client's arm.
C. Remove the IV site dressing.
D. Flush the lock with saline.
40. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain?
A. Sensory pattern, area, intensity, and nature of the pain.
B. Trigger points identified by palpation and manual pressure of painful areas.
C. Schedule and total dosages of drugs currently used for breakthrough pain.
D. Sympathetic responses consistent with onset of acute pain.
41. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
A. Use disposable plates and utensils.
B. Stay in a room with the door closed.
C. Dispose of soiled dressings in plastic bags that are securely closed.
D. Others who are in the same room with the client should wear a mask.
42. The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light because the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?
A. Page the unit manager to address the situation.
B. Close the demographic screen on the computer.
C. Instruct the UAP to end the phone call immediately.
D. Send a UAP into the client's room to relieve the nurse.
43. 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?
A. Lightly coat the wound with povidone-iodine solution
B. Irrigate the wound with sterile normal saline
C. Flush the wound with sterile hydrogen peroxide
D. Remove the eschar with a wet-to-dry dressing
44. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
A. Document the client’s circadian rhythms
B. Assess for flushed, warm skin regularly
C. Measure temperature at regular intervals
D. Vary sites for temperature measurement
45. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?
A. Position the client supine for a few minutes
B. Assist the client to stand at the bedside
C. Apply the blood pressure cuff securely
D. Record the client’s pulse rate and rhythm
46. 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 client. When the family leaves, what action should the nurse take first?
A) Apply the restraints to maintain the client’s safety.
B) Reassess the client to determine the need for continuing restraints.
C) Document the time the family left and continue to monitor the client.
D) Call the healthcare provider for a new prescription.
47. 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) Potassium 3.1mEq/L (3.1 mmil/L)
B) Sodium 142 mEq/L (142 mmol/L)
C) Total calcium 9.2 mg/dl (2.3 mmol/L)
D) Chloride 98 mEq/L (98 mmil/L)
48. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
A) Between the toes.
B) Around the ankles.
C) On dorsal surfaces
D) Over the heels.
49. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath?
A. Take measures to promote as much comfort as possible.
B. Report any signs of drug addiction to the nurse immediately.
C. Wait until the client's pain is gone before assisting with personal care.
D. This client's pain will be difficult to manage, since the cause is unknown.
50. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair?
A. Use a mechanical lift to transfer from the bed to a chair.
B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed.
51. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client?
A. Use distraction techniques during times of spiritual stress and crisis.
B. Reassure the client that his faith will be regained with time and support.
C. Consult with the staff chaplain and ask that the chaplain visit with the client.
D. Use reflective listening techniques when the client expresses spiritual doubts.
52. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first?
A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
B. Retake the blood pressure in the same arm, deflating the cuff slowly.
C. Ask another nurse to recheck the blood pressure to compare results.
D. Obtain another blood pressure cuff and retake the blood pressure.
53. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client?
A. Help the client to accept the final stage of 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. Instruct the client's family to focus on positive aspects of the client's life.
54. What is the most effective way to implement a teaching plan?
A. Teach the information that the client wants to learn first.
B. Streamline the teaching plan to include only essential information.
C. Present to the client all the information necessary to meet the objectives.
D. Provide the client with written material to review before teaching sessions.
55. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement?
A. Confirm the finding by further assessing the client for jugular vein distention.
B. Offer the client high protein snacks between regularly scheduled mealtimes.
C. Continue the planned nursing interventions to restore the client's fluid volume. Correct
D. Change the plan of care to include a nursing diagnosis of impaired skin integrity. [Show Less]