HESI FUNDAMENTALSC UPDATED SCRIPT EXAM
QUESTIONS AND ANSWERS GRADED A+
✔✔A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - ✔✔C. demonstrates the wound care
procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the
client's ability to perform a task, while (A and B) are subjective measures. (D) is
important, but is less of a priority than the the nurse's assessment of the client's ability
to complete wound care.)
✔✔A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the preoperative
assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?" - ✔✔B. "What vitamin and mineral
supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the
operative period. (A and C) are appropriate questions for long-term dietary counseling.
The nature of the surgery and anesthesia will determine the need for a clear liquid diet
(D), rather than the client's preference.)
✔✔During the initial morning assessment, a male client denies dysuria but reports that
his urine appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ✔✔D. Encourage additional
oral intake of juices and water.
✔✔Which intervention is most important for the nurse to implement for a male client
who is experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - ✔✔D. Assess the bladder for distention (Urinary
retention is the inability to void all urine collected in the bladder, which leads to
,uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of
a client with urinary incontinence. (C) may worsen the bladder distention.)
✔✔A client with acute hemorrhagic anemia is to receive four units of packed RBCs as
rapidly as possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up
C. Monitor vital signs q 15 min for the first hour.
D. Ensure the accuracy of the blood type match. - ✔✔D. Ensure the accuracy of the
blood type match.
(ALL interventions should be implemented prior to administering blood, but (D) has the
highest priority. Any time blood is administered the nurse should ensure the accuracy of
the blood type match in order to prevent a possible hemolytic reaction.)
✔✔A male client being discharged with a prescription for the bronchodilator theophylline
tells the nurse that he understands he is to take three doses of the medication each
day. Since, at the time of discharge, time-released capsules are not available, which
dosing schedule should the nurse advise the client to follow? - ✔✔8 AM, 4 PM, and
midnight
(Theophylline should be administered on a regular around the clock schedule to provide
the best bronchodilating effect and reduce the potential for adverse effects.)
✔✔A client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours.
At what rate should the nurse set the client's intravenous infusion pump? - ✔✔63 mL/hr
✔✔When evaluating a client's plan of care, the nurse determines that a desire outcome
was not achieved. Which action should the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes. - ✔✔B. Note which actions were not
implemented.
(First, the nurse should review which actions in the original plan were not implemented
(B) in order to determine why the original plan did not produce the desired outcome.
Appropriate revisions can then be made, which may include revising the expected
outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing
actions were unsuccessful, or were unable to be implemented. (D) other members of
the healthcare team may be necessary to collaborate changes once the nurse
determines why the original plan did not produce the desired outcome.
✔✔Which snack food is best for the nurse to provide a client with myasthenia graves
who is at risk for altered nutritional status?
A. chocolate pudding
B. graham crackers
C. sugar free gelatin
, D. apple slices - ✔✔A. chocolate pudding
(The client with myasthenia graves is at high risk for altered nutrition because of fatigue
and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as
pudding (A) are easy to swallow and require minimal chewing effort, and provide
calories and protein. (C) does not provide any nutritional value. (B and D) require
energy to chew and are more difficult to swallow than pudding.)
✔✔The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase." - ✔✔C. "I will limit my
intake of beef to 4 ounces per week."
(Limiting saturated fat from animal food sources to no more than 4 ounces per week (C)
is an important diet modification for lowering cholesterol. To be effective in reducing
cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per
week (A). Red meat and all proteins do not need to be eliminated (B) to lower
cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-
ounce servings). The low density lipoproteins (D) need to decrease rather than
increase.)
✔✔An obese male client discusses with the nurse his plans to begin long-term weight
loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic
exercise program 3 to 4 times a week and to take stress management classes. After
praising the client for his decision, which instruction is most important for
the nurse to provide?
A. "Be sure to have a complete physical examination before beginning your planned
exercise program."
B. "Be careful that the exercise program doesn't simply add to your stress level, making
you want to eat more."
C. "Increased exercise helps to reduce stress, so you may not need to spend money on
a stress management class."
D. "Make sure to monitor your weight loss regularly to provide a sense of
accomplishment and motivation." - ✔✔A. "Be sure to have a complete physical
examination before your planned exercise program."
(The most important teaching is (A), so that the client will not begin a dangerous level of
exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or
stroke. (B, C, and D) are important instructions, but are of less priority than (A). )
✔✔The nurse is teaching a client proper use of an inhaler. When should the client
administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
A. Immediately after exhalation.
B. During the inhalation
C. At the end of three inhalers
QUESTIONS AND ANSWERS GRADED A+
✔✔A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - ✔✔C. demonstrates the wound care
procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the
client's ability to perform a task, while (A and B) are subjective measures. (D) is
important, but is less of a priority than the the nurse's assessment of the client's ability
to complete wound care.)
✔✔A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the preoperative
assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?" - ✔✔B. "What vitamin and mineral
supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the
operative period. (A and C) are appropriate questions for long-term dietary counseling.
The nature of the surgery and anesthesia will determine the need for a clear liquid diet
(D), rather than the client's preference.)
✔✔During the initial morning assessment, a male client denies dysuria but reports that
his urine appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ✔✔D. Encourage additional
oral intake of juices and water.
✔✔Which intervention is most important for the nurse to implement for a male client
who is experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - ✔✔D. Assess the bladder for distention (Urinary
retention is the inability to void all urine collected in the bladder, which leads to
,uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of
a client with urinary incontinence. (C) may worsen the bladder distention.)
✔✔A client with acute hemorrhagic anemia is to receive four units of packed RBCs as
rapidly as possible. Which intervention is most important for the nurse to implement?
A. Obtain the pre-transfusion hemoglobin level.
B. Prime the tubing and prepare a blood pump set-up
C. Monitor vital signs q 15 min for the first hour.
D. Ensure the accuracy of the blood type match. - ✔✔D. Ensure the accuracy of the
blood type match.
(ALL interventions should be implemented prior to administering blood, but (D) has the
highest priority. Any time blood is administered the nurse should ensure the accuracy of
the blood type match in order to prevent a possible hemolytic reaction.)
✔✔A male client being discharged with a prescription for the bronchodilator theophylline
tells the nurse that he understands he is to take three doses of the medication each
day. Since, at the time of discharge, time-released capsules are not available, which
dosing schedule should the nurse advise the client to follow? - ✔✔8 AM, 4 PM, and
midnight
(Theophylline should be administered on a regular around the clock schedule to provide
the best bronchodilating effect and reduce the potential for adverse effects.)
✔✔A client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours.
At what rate should the nurse set the client's intravenous infusion pump? - ✔✔63 mL/hr
✔✔When evaluating a client's plan of care, the nurse determines that a desire outcome
was not achieved. Which action should the nurse implement first?
A. Establish a new nursing diagnosis.
B. Note which actions were not implemented.
C. Add additional nursing orders to the plan.
D. Collaborate with the HCP to make changes. - ✔✔B. Note which actions were not
implemented.
(First, the nurse should review which actions in the original plan were not implemented
(B) in order to determine why the original plan did not produce the desired outcome.
Appropriate revisions can then be made, which may include revising the expected
outcome, or identifying a new nursing diagnosis (A). (C) may be needed if the nursing
actions were unsuccessful, or were unable to be implemented. (D) other members of
the healthcare team may be necessary to collaborate changes once the nurse
determines why the original plan did not produce the desired outcome.
✔✔Which snack food is best for the nurse to provide a client with myasthenia graves
who is at risk for altered nutritional status?
A. chocolate pudding
B. graham crackers
C. sugar free gelatin
, D. apple slices - ✔✔A. chocolate pudding
(The client with myasthenia graves is at high risk for altered nutrition because of fatigue
and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as
pudding (A) are easy to swallow and require minimal chewing effort, and provide
calories and protein. (C) does not provide any nutritional value. (B and D) require
energy to chew and are more difficult to swallow than pudding.)
✔✔The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. "If I exercise at least two times weekly for one hour, I will lower my cholesterol."
B. "I need to avoid eating proteins, including red meat."
C. "I will limit my intake of beef to 4 ounces per week."
D. "My blood level of low density lipoproteins needs to increase." - ✔✔C. "I will limit my
intake of beef to 4 ounces per week."
(Limiting saturated fat from animal food sources to no more than 4 ounces per week (C)
is an important diet modification for lowering cholesterol. To be effective in reducing
cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per
week (A). Red meat and all proteins do not need to be eliminated (B) to lower
cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-
ounce servings). The low density lipoproteins (D) need to decrease rather than
increase.)
✔✔An obese male client discusses with the nurse his plans to begin long-term weight
loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic
exercise program 3 to 4 times a week and to take stress management classes. After
praising the client for his decision, which instruction is most important for
the nurse to provide?
A. "Be sure to have a complete physical examination before beginning your planned
exercise program."
B. "Be careful that the exercise program doesn't simply add to your stress level, making
you want to eat more."
C. "Increased exercise helps to reduce stress, so you may not need to spend money on
a stress management class."
D. "Make sure to monitor your weight loss regularly to provide a sense of
accomplishment and motivation." - ✔✔A. "Be sure to have a complete physical
examination before your planned exercise program."
(The most important teaching is (A), so that the client will not begin a dangerous level of
exercise when he is not sufficiently fit. This might result in chest pain, a heart attack, or
stroke. (B, C, and D) are important instructions, but are of less priority than (A). )
✔✔The nurse is teaching a client proper use of an inhaler. When should the client
administer the inhaler-delivered medication to demonstrate correct use of the inhaler?
A. Immediately after exhalation.
B. During the inhalation
C. At the end of three inhalers
