NURS HESI HESI PN FUNDAMENTAL 2023 Walden University/NURS HESI HESI PN FUNDAMENTAL 2023 Walden University/NURS HESI HESI PN FUNDAMENTAL 2023 Walden
... [Show More] University/NURS HESI HESI PN FUNDAMENTAL 2023 Walden University
HESI PN FUNDAMENTAL 2023
1. A 35 year old female client with cancer refuses to allow the nurse to insert an IV for a
scheduled chemotherapy treatment, and states that she is ready to go home and die. What
intervention should the nurse initiate?
A. evaluate the client's mental status for competence to refuse treatment
B. review the client's medical record for an advance directive
C. determine if a DNR prescription has been obtained
D. document that the client is being discharged against medical advice
2. A client with chronic renal disease is admitted to the hospital for evaluation prior to a
surgical procedure. Which laboratory test indicated the client's protein status for the longest
length of time.
A. Urine urea
B. transferrin
C. prealbumin
D. serum albumin
3. What client statement indicates to the nurse that the client requires assistance with
bathing?
A. "I only bathe every other day"
B. "I left my eyeglasses at home"
C. "I don't understand why I'm so weak and tired"
D. "I wasn't able to pack a bag before I left for the hospital"
4. How should a nurse handle linens that are soiled with incontinent feces?
A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper
B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper
C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room
D. place an isolation hamper in the client's room and discard the linens in it.
5. When caring for an immobile client, what nursing diagnosis has the highest priority?
A. altered tissue perfusion
B. impaired gas exchange
C. risk for fluid volume deficit
D. risk for impaired skin integrity
6. The nurse assess an immobile, elderly male client and determines that his blood pressure is
138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the
last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on
these assessment findings, what nursing action is the most important for the nurse to
implement?
A. encourage additional additional fluid intake
B. provide the client with an additional blanket
C. turn the patient Q2
D. administer a PRN anti hypertensive prescription
7. The home health nurse visits an elderly female client who had a brain attack three months
ago and is now able to ambulate with the assistance of a quad cane. Which assessment
finding has the greatest implications for this client's case?
A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago
B. the client tells the nurse that she does not have much of an appetite today
C. the husband, who is the caregiver, begins to weep when you ask how he is doing
D. the nurse notes that there are numerous scatter rubs throughout the house.
8. The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch
in diameter and finds that there is straw-colored drainage seeping from the wound. What
description of this finding should the nurse include in the client's record?
A. stage 1 pressure sore draining sero-anguineous drainage
B. one-inch pressure sore draining serous fluid
C. pressure sore draining serous fluid
D. pressure sore on heel with a small amount of purulent drainage.
9. A medication is prescribed to be given QID. What schedule should the nurse use to
administer this prescription?
A. 800
B. 0800, 1200, 1600, 2000
C. every other day at 0800
D. 0800, 1200, 1600, 2000, 0000, 0400
10. The nurse working in the emergency department is assessing four client's ability to tolerate
pain. Which client is likely to tolerate a higher level of pain.
A. A 23-year-old woman who sprained her knee while biking
B. a 55-year-old woman who has had moderate low back pain for three months
C. A 10-year-old who was burned by a camp fire earlier today
D. A 70 year-old who has a postoperative infection from a surgery one week ago.
11. A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "
will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse
to provide?
a. "It won't hurt because you're such a big boy"
b. "It may hurt a little because of the incision made in your throat"
c. "It won't hurt because we put you to sleep"
d. "It may hurt but we'll give you medicine to help you feel better".
12. A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency
and hypertension, who gained 3 pounds in the last month. The nurse determines that the
client has been non compliant with the diet, based on which report from the 24-hour dietary
recall? (select all that apply)
A. bedtime snack of crackers and milk
B. breakfast of eggs, bacon, toast, and coffee
C. lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee
D. dinner of vegetable lasagna, tossed salad, sherbet, and iced tea
E. snack of potato chips, and diet soda.
13. 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 a chronic venous insufficiency?
A. check capillary refill of toes on lower extremity with Unna's paste boot
B. apply dressing to a wound area before applying the Unna's paste boot
C. remove the Unna's paste boot Q8H to assess wound healing
D. wrap the leg from the knee down towards to foot.
14. A male client has a nursing diagnosis of "spiritual distress". What intervention is best for the
nurse to implement when caring for the client.
A. Reassurance the client that his faith will be regained with time and support
B. consult with the staff chaplain and ask that the chaplain visit with the client
C. use reflective listening techniques when the client expresses spiritual doubts
D. use distraction techniques during times of spiritual stress and crisis.
15. A client has a nursing diagnosis of "Spiritual distress related to loss of hope, secondary to
impending death." What intervention is best for the nurse to implement when caring for this
client?
A. instruct the client's family to focus on positive aspect of the client's 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. help the client to accept the final stage of life.
16. A female nurse who sometimes tries to save time by putting medications in her uniform to
clients, confides that after arriving home she found hydrocodone (Vicodin) tablet in her
pocket. Which possible outcome of this situation should be the nurse's greatest concern?
a. accused of unprofessional conduct
b. accused of diversion
c. reported for stealing
d. reported for a HIPAA violation
17. A signed consent form indicated a client should have an EKG, but a myelogram was
performed instead. Though the myelogram revealed the cause of the client's back pain,
which was subsequently treated, the client filed a lawsuit against the nurse and healthcare
provider for performing the incorrect procedure. The court is likely to rule in favor of the
plantiff because these events represent which infraction?
A. An unintentional tort because the client benefited from having the myelogram
B. Assault and battery with deliberate intent to deviate from the consent form
C. A quisi-intentional because a similar mistake can happen to anyone
D. failure to respect client autonomy to choose based on international tort law.
18. A 75 year old client who has a history of end stage renal failure and advanced lung cancer,
recently had a stroke. Two days ago the healthcare provider discontinued the client's
dialysis treatments, starting the death is inevitable, but the client is discontinues and will
not sign a DNR directive.
A. review the client's most recent laboratory reports
B. determine who is legally empowered to make decisions
C. refer the client and family members for hospice
D. notify the patient ethics committee of the client situation.
19. The change nurse assigns a nursing procedure to a new staff nurse who has not previously
performed the procedure. What action is most important for the new staff nurse to take?
A. review the steps in the procedural manual
B. refuse to perform the task that is beyond the nurse's experience
C. ask another nurse to assist while implementing the procedure
D. follow the agency's policy and procedure
20. Before administering a client's medication, the nurse assesses a change in the client's
condition and decides to withhold the medication until consulting with the health care
provider. After consultation with the health care provider, the dose of the medication is
changed and the nurse administers the newly prescribed dose an hour later than the
originally scheduled time. What action should the nurse implement in response to this
situation?
A. Document the events that occurred in the nurse's notes
B. notify the charge nurse that a medication error occurred
C. submit a medication valence report to the supervisor
D. discard the original medication administration record.
21. On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel elimination?
A. provide warm prune juice before the client goes to bed at night
B. teach the client to splint the incision while walking to the bathroom
C. remind the client to turn every two hours while lying in bed
D. administer an analgesic before the client attempts to defecate
22. The home health nurse visits an elderly client who lives at home with her husband. The
client is experiencing frequent episodes of diarrhea and bowel incontinence. Which
problem, for which the client is at risk, has the greatest priority when planning the client's
care?
A. fluid volume imbalance
B. impaired skin integrity
C. caregiver role strain
D. disturbed sleep pattern
23. A nurse observes a student nurse taking a copy of a client's medication administration
record. When questioned, the student states, "Another student is scheduled to administer
medications for this client tomorrow, so I am going to make a copy to help my friend
prepare for tomorrow's clinical". What response should the nurse provide first?
A. Ask the nursing supervisor to meet with the students
B. Ask the client if permission was obtained from the client
C. explain the records are hospital property and may not be removed
D. notify the student's clinical instructor of the situation.
24. After a client has been premedicated for surgery with an opioid analgesic, the nurse
discovers that the operative permit has not been signed. What action should the nurse
implement?
A. read the consent form to the client before witnessing the client's signature
B. determine if the client's spouse is willing to sign the consent form
C. notify the surgeon that the consent form has not been signed
D. administer an opioid antagonist prior to obtaining the client's signature
25. A client who has been on bedrest for several days now has a prescription to progress
activity as tolerated. When the nurse assists the client out of bed for the first time, the client
becomes dizzy. What action should the nurse implement?
A. Instruct the patient to remain on bedrest until the healthcare provider is contracted
B. encourage the client to take several slow, deep breaths while ambulating
C. advise the client to sit on the side of the bed for a few minutes before standing again
D. help the client to remain standing by the bedside until the dizziness is relieved.
26. The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to
lift a 20-pound box of medical supplies off the treatment room floor. What instruction
should the charge nurse provide to the UAP?
A. ask another staff member for assistance
B. request that supplies are delivered in smaller containers
C. push the box against the wall to provide support while lifting
D. bend at the knees when lifting heavy objects.
27. An older female client with rheumatoid arthritis is complaining of severe joint pain that is
caused by the weight of the linen on her legs. What action should the nurse implement first?
A. apply flannel pajamas to provide warmth
B. administer a PRN dose of ibuprofen
C. Drape the sheets over the foot board of the bed
D. perform ROM exercises in a warm tub.
28. A client is admitted to the hospital with intractable pain. When instruction should the nurse
provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with
a bed bath?
A. a client's pain will be difficult to manage, since the cause is still unknown
B. take measures to promote as much comfort as possible
C. report any signs of drug addiction to the nurse immediately
D. wait until the client's pain is gone before assisting with personal care.
29. A male client arrives at the out patient surgery center for a scheduled needle aspiration of
the knee. He tells the nurse that he has already given verbal consent for the procedure to the
health care provider. What action should the nurse implement?
A. verify the client's consent with the health care provider
B. document that the client has given consent for the needle aspiration
C. witness the client's signature on the consent form
D. notify the healthcare provider that the client is ready for the procedure.
30. In assessing a client's femoral pulse, the nurse must use deep pulsation to feel the pulsation
while the client is in a supine position. What action should the nurse implement?
A. document the presence and volume of the pulse palpated
B. elevate the head of the bed and attempt to palpate the site again
C. record the presence of pitting edema in the inguinal area
D. use a thigh cuff to measure the blood pressure in the leg.
31. A nurse is preparing to insert a rectal suppository and observes a small amount of rectal
bleeding. What action should the nurse implement?
A. insert the suppository very gently being careful not to further injure the rectal bleeding.
What action should the nurse implement?
A. insert the suppository very gently being careful not to further the rectal mucosa
B. withhold the administration of the suppository until contacting the healthcare provider
C. administer the medication as scheduled after assessing the client's vital signs
D. Ask the pharmacist to send an alternate from the prescribed medication to the unit
32. The nurse is preparing to irrigate a client's indwelling catheter using an open technique.
What action should the nurse take after applying gloves?
A. Draw up the irrigating solution into the syringe
B. use aseptic technique to instill the irrigating solution
C. empty the client's urinary catheter
D. secure the client's catheter to the drainage tubing
33. When assessing a client with an indwelling urinary catheter, which observation requires the
most immediate intervention by the nurse?
A. there are no dependent loops in the drainage tubing
B. the clamp on the urinary drainage bag is open
C. the drainage tubing is secured over the siderail
D. the urinary drainage bag is attached to the bed frame
34. While preparing to insert a rectal suppository in a male adult client, the nurse observes that
the client is holding his breath while bearing down. What action should the nurse
implement?
A. gently insert the lubricated suppository four inches into the rectum
B. instruct the client to take slow deep breaths and stop bearing down
C. advise the client to continue to bear down without holding his breath
D. perform a digital exam to determine a fecal impaction is present
35. The nurse is completing the plan of care for a client who is admitted for benign prostatic
hypertrophy. Which data should the nurse document as a subjective findings?
A. complains of inability to empty bladder
B. temperature of 99.80F and pulse of 108
C. post-voided residual volume of 750ml
D. specimen collection for culture and sensitivity
36. While the nurse is administering a bolus feeding to a client via NG tube, the client begins to
vomit. What action should the nurse implement first?
A. discontinue the administration of the bolus feeding
B. administer a PRN dose of a prescribed antiemetic
C. auscultate the client's breath sounds bilaterally
D. elevate the head of the bed to a high fowler's position
37. What is the rationale for using the nursing process in planning care for clients?
A. to establish nursing theory that incorporates the biopsychosocial nature of humans
B. as a scientific process to identify nursing diagnoses of a client's healthcare problems
C. to promote the managment of client care in collaboration with other health care
professionals
D. as a tool to organize thinking and clinical decision making about clients' healthcare needs.
38. What activity should the nurse use in the evaluation phase of the nurse process?
A. ask a client to evaluate the nursing care provided
B. examine the effectiveness of nursing interventions toward meeting client outcomes
C. determine whether a client's health problems have been alleviated
D. document the nursing care plan in the progress notes
39. Which statement is an example of a correctly written nursing diagnosis statement?
A. ineffective coping related to response to positive biopsy
B. risk for impaired tissue integrity
C. altered tissue perfusion related to congestive heart failure
D. altered urinary elimination related to urinary tract infection
40. What action by the nurse demonstrated culturally sensitive care?
A. explains the differences between western medical care and cultural folk remedies
B. applies knowledge of a cultural group unless a client embraces western customs
C. avoids questions about male-female relationship
D. asks permission before touching a client
41. A nurse is becoming increasingly frustrated by the family members' efforts to participate in
the care of a hospitalized client. What action should the nurse implement to cope with these
feelings of frustration?
A. allow the situation to continue until a family member's action may harm the client
B. explain to the family that multiple visitors are exhausting to the client
C. explain one's own culturally based values, beliefs, attitudes and practices
D. suggest that other cultural practices be substituted by the family members
42. Which technique is most important for the nurse to implement when performing a physical
assessment?
A. the medical systems model
B. an approach related to a nursing model
C. a consistent, systemic approach
D. a head-to-toe approach
43. A 73 year old Hispanic client is seen at the community health clinic with a history of protein
malnutrition. What information should the nurse obtain first?
A. foods and liquids consumed during the past 24 hours
B. amount of liquid protein supplements consumed daily
C. grains and legume combinations used by the client
D. usual weekly intake of milk products and red meats
44. The nurse formulates the nursing diagnosis of "ineffective health maintenance related to
lack of motivation" for a client with type 2 diabetes. Which finding supports this nursing
diagnosis?
A. does not check capillary blood glucose as directed
B. cannot identify signs or symptoms of high and low blood glucose
C. occasionally forgets to take daily prescribed medication
D. eats anything and does not think diet makes a difference in health
45. Which statement correctly identifies a written learning objective for a client with peripheral
vascular disease?
A. the nurse will provide client instruction for daily foot care
B. upon discharge, the client will list three ways to protect the feet from injury
C. after instruction, the nurse will ensure the client understands foot care rationale
D. the client will demonstrate proper trimming toenail technique
46. A middle-aged woman who enjoys being a teacher a mentor feels that she should pass down
her legacy of knowledge and skills to the younger generation. According to Erikson, she is
involved in what developmental stage?
A. valuing wisdom
B. generativity
C. ego integrity
D. Identification
47. which statement best describes durable power of attorney for health care?
A. the healthcare decisions made my another person designated by the client are not legally
binding
B. instructions about actions to be taken in the event of a client's terminal or irreversible
condition are not legally binding
C. the client signs a document that designated another person to make legally binding
healthcare decisions if client is unable to do so
D. directions regarding care in the event of a terminal or irreversible condition must be
documented to ensure that they are legally binding.
48. A male client with an infected wound tells the nurse that he follows a macrobiotic diet.
Which type of foods should the nurse recommend that the client select from the hospital
menu?
A. increased amount of vitamin c and beta carotene rich foods
B. limited complex carbohydrates and fiber
C. low fat and low sodium foods
D. combination of plant proteins to provide essential amino acids
49. A client with raynaud's disease asks the nurse about using biofeedback for selfmanagement of symptoms. What response is best for the nurse to provide?
A. although biofeedback is easily learned, it is mostly often used to manage exacerbation of
symptoms
B. biofeedback allows the client to control voluntary responses to promote peripheral
vasodilation
C. the responses to biofeedback have not been well established and may be a waste of time
and money
D. biofeedback requires extensive training to retain voluntary muscles, not involuntary
50. A female client informs the nurse that she uses herbal therapies to supplement her diet and
manage common ailments. What information should the nurse offer the client about general
use of herbal supplements?
A. herbal therapies may mask the symptoms of serious disease, so frequent medical
evaluation is requiring during use
B. herbs should be obtained from manufacturers with a history of quality control of their
supplements
C. there is no evidence that herbs are safe or effective as compared to conventional
supplements in maintaining health
D. most herbs are toxic of carcinogenic and should be used only when proven effective.
51. Older female client can't sleep at night. Nurse recommends SATA
A. Take afternoon nap
B. Ask HCP for prescription of mild sedative at bedtime
C. Establish regular time for getting up and going to bed
D. Drink whiskey, water and honey before bed
E. Avoid drinking caffeine before bedtime
52. The nurse has been alerted by the EMR when scanning the dispensed medication that the
dosage is two times higher than the prescribed dose. The nurse should:
A. Report mismatch of prescription and available dosages
B. Withhold medication until exact dose is available
C. Ask pharmacy if another dose can be dispensed
D. Calculate dose on hand to match the prescribed dose
53. A patient diagnosed with small bowel obstruction refuses surgery. The nurse should:
A. Assess client needs for antiemetics and pain medications
B. Prepare nasogastric tube compress
C. Sent patient to CT abdominal scan
D. Notify HCP that patient refuses surgery
54. What is the most important factor for obesity referral?
A. BMI >35
B. Client expressed desire to lose 50 pounds
C. Body weight is 10% over ideal weight
D. Daily calorie intake is 3,500
55. An elderly patient returns to the clinic for chronic pain management. He is prescribed MS
Contin PO Q12H. He states that he only takes it when the pain is so severe that he can't
sleep.
A. Long time use of opioids may cause drug addiction
B. Take medication Q12H as prescribed
C. Teach alternative methods for pain management
D. Continue taking MS Contin for severe pain.
56. IM ventrogluteal landmark
A. Upper outer quadrant of buttock
B. Deltoid
C. Knee and greater trochanter
D. Greater trochanter and anterior superior iliac spine
57. A client with a nasogastric tube is receiving low intermittent suction and is complaining of
dry mouth. What should the nurse implement?
A. Tell the client that the mucosa must stay dry to prevent aspiration
B. Turn off suction so that the client can rinse his mouth with cold water
C. Provide oral sponge toothettes so the client can clean and moisten his mouth
D. Instill 50 mL of normal saline and clamp
58. A client who is 12 days post op complains of thoracic incisional pain 2 hours after he
received his pain medication. The HCP has been called. What should the nurse do next?
A. Guided imagery and deep breathing
B. Turn on a T.V. show and music for distraction
C. Put a hot device on the area
D. Provide a 20 minute back massage
59. A post-op patient is grimacing when moving from bed to chair but denies pain. What should
the nurse do next?
A. Administer pain medication PRN
B. Review his pain medications that are prescribed
C. Monitor patient's nonverbal actions
D. Ask what is making him grimace
60. A client is on a mechanical soft diet and is constipated. He requests for prune juice. The
nurse should:
A. Restrict fluid
B. Initiate bowel training protocol
C. Advance to regular diet
D. Offer to warm up the prune juice.
61. The nurse is assessing a client's ability to perform activities of daily living (ADL) safely. The
client has steady gait and is able to ambulate from the door to the bed with full ROM. The
nurse should:
A. Teach the client to take shorter strides for better balance
B. Record client's ability to perform ADL safely
C. Initiate fall risk protocol
D. Determine client's activity tolerance
62. A patient is demonstrating diaphragmatic breathing by holding her abdomen while inhaling
and removing her hands during exhalation.
A. The demonstration was successful
B. The hands do not need be on the abdomen, but the demonstration was still correct
C. Keep light pressure on abdomen and cough after inspiration
D. Expand abdomen during inspiration and let the abdomen sink during exhalation.
63. Highest priority?
A. Impaired bed mobility
B. Fluid volume deficit
C. Bowel incontinence
D. Caregiver role strain
64. The computer system shuts down while the nurse was inputting client data. What should
the nurse do next?
A. Print EMR from backup server
B. Wait for notification that the EMR is rebooted
C. Identify information as late entry
D. Notify IT
65. The student nurse assesses an adult client's TM by pulling the ear up and back. The
preceptor:
A. Provides positive reinforcement to the student nurse for using correct technique
B. Tells the student nurse that the ear should be pulled down
66. Which related data should be obtained if a client is wheezing?
A. Radiates to other parts of the body
B. Heart sounds
C. Body temperature
D. Precipitating factors
67. Picture of a nurse about to open an ampule. What should the nurse do next?
A. Clean neck of ampule with alcohol
B. Position gauze around neck of ampule
C. Apply clean gloves before breaking the ampule open
D. Snap neck away from hands
68. UAP is not fitted for a respirator mask and requests to be re-assigned from a client with
droplet precautions. The charge nurse should:
A. Before changing assignments, check to see which nurses are fitted for the respirators
B. Send UAD to get fitted for the respirator immediately so that she can return to take care of
the patient
C. Tell the UAP that she can wear a standard mask during vitals and use a respirator mask
for other tasks
D. Tell the UAP that a standard face mask is sufficient.
69. Patient complains that he hates how his boss orders him around and how he doesn't listen
to his ideas. What is the nurse's best response?
A. "I'm sure that it will get better with time."
B. "It must be difficult for you to work in a place that makes you feel so bad."
C. "How do you feel when your boss doesn't listen to you?"
D. "You should change how you interact with your boss."
70. A Native American client complains of abdominal cramping and nausea. What is the most
important factor to assess?
A. Family decision-making regarding health
B. Recent use of home remedies and herbs
C. Employment status
71. A patient with a latex allergy needs a dressing change. The nurse notices redness on the skin
around the draining wound. The nurse should:
A. Obtain sample from draining wound
B. Replace dressing with cotton gauze and silk tape
C. Measure ankle to brachial index
D. Administer antibiotics
72. A nurse is educating a client on 24-hour urine test. The client states that the first void is in
the urinal.
A. Add the urine from the urinal to the collection container
B. Start collecting with next void
C. Start collecting the next day
D. Check urine for sediments
73. Which is the most appropriate method to teach young adults?
A. Simulation activities
B. Positive reinforcement
C. Physical demonstrations
D. Verbal analogies
74. What to assess first for a client with cyanosis
A. Temperature
B. Heart rate
C. Blood pressure
D. Respiratory rate
75. What should the nurse implement when inserting an indwelling catheter to an
uncircumcised male.
A. Clean meatus before retracting the foreskin
B. Advance catheter before inflating balloon
C. Sterile field should be even between nurse's hips
D. Wipe the meatus back and forth
76. A nurse notices a fire in the bathroom of an empty room and reports the location of the fire
immediately. What should the nurse do next?
A. Close the door to all the client's rooms in the hallway
B. Evacuate clients in the rooms close to the fire
C. Shut the door to the bathroom and the empty room
D. Obtain fire extinguisher on the unit [Show Less]