HESI FUNDAMENTALS PRACTICE
EXAM #1
A-35y/o-client-with-cancer-refuses-to-allow-a-nurse-to-insert-an-IV-for-scheduled-chemo-&-
states-that-she's-ready-to-go-home-to-die.-What-intervention-should-the-nurse-initiate?---
ans-✔✔Evaluate-the-client's-mental-status-for-competence-to-refuse-treatment
Rationale:-Competent-clients-have-the-right-to-refuse-treatment.-The-nurse-cannot-
document-until-the-HCP-is-notified-of-the-patient's-wishes-&-a-d/c-RX-is-obtained.-
Advance-directives-&-DNR-are-not-necessary-for-competent-client-to-refuse-care.
A-client-with-chronic-renal-disease-is-admitted-to-the-hospital-for-evaluation-prior-to-a-
surgical-procedure.-Which-laboratory-test-indicates-client's-protein-status-for-the-longest-
length-of-time?---ans-✔✔Serum-albumin
Rationale:-Serum-albumin-has-a-long-half-life.
What-client-statement-indicates-to-the-nurse-that-the-client-requires-assistance-with-
bathing?---ans-✔✔"I-don't-understand-why-I'm-so-weak-&-tired."
How-should-the-nurse-handle-linens-that-are-soiled-with-incontinent-feces?---ans-
✔✔Place-the-soiled-linens-in-a-pillow-case-&-deposit-them-in-the-dirty-linen-hamper
When-caring-for-an-immobile-client,-what-nursing-diagnosis-has-the-highest-priority?---
ans-✔✔Impaired-gas-exchange
The-nurse-assesses-an-immobile,-elderly-male-client-&-determines-that-his-blood-
pressure-is-138/60,-his-temperature-is-95.8F-&-his-output-is-100-mL-of-concentrated-urine-
during-the-last-hour.-He-has-wet-sounding-lungs-&-increased-respiratory-secretions.-
Based-on-these-assessment-findings-,-what-nursing-action-is-most-important-for-the-nurse-
to-implement?---ans-✔✔Turn-the-client-q2h
Rationale:-It-will-help-move-&-drain-respiratory-secretions-&-prevent-pneumonia-from-
occurring.
The-home-health-nurse-visits-an-elderly-female-client-who-had-a-brain-attack-3-months-
ago-&-is-now-able-to-ambulate-with-the-assistance-of-a-quad-cane.-Which-assessment-
, finding-has-the-greatest-implications-for-this-client's-care?---ans-✔✔The-nurse-notes-
there-are-numerous-scatter-rugs-throughout-the-house
The-nurse-removes-the-dressing-on-a-client's-heel-that-is-cover-a-pressure-sore-1"-in-
diameter-&-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?---ans-✔✔One-
inch-pressure-sore-draining-serous-fluid
Medication-is-prescribed-to-be-given-QID.-What-schedule-should-the-nurse-use-to-
administer-this-Rx?---ans-✔✔0800,-1200,-1600,-2000
The-nurse-working-in-the-ED-is-assessing-4-clients'-ability-to-tolerate-pain.-Which-client-is-
likely-to-tolerate-a-higher-level-of-pain?---ans-✔✔1-55y/o-woman-who-has-had-moderate-
low-back-pain-for-3-months
Rationale:-Experiences-with-the-same-type-of-pain-that-has-successfully-been-relieved-
makes-it-easier-for-the-client-to-interpret-the-pain-sensation-and,-as-a-result,-the-client-is-
better-prepared-to-take-steps-to-relieve-the-pain.-All-other-clients-are-having-new-
experiences-with-pain.
A-4y/o-boy-who-is-scheduled-for-a-tonsillectomy-&-adenoidectomy-asks-the-nurse,-"Will-it-
hurt-to-have-my-tonsils-&-adenoids-taken-out?"-Which-response-is-best-for-the-nurse-to-
provide?---ans-✔✔"It-may-hurt,-but-we'll-give-you-medicine-to-help-you-feel-better."
A-low-sodium,-low-protein-diet-is-prescribed-for-a-45y/o-client-with-renal-insufficiency-&-
HTN,-who-gained-3lbs-in-the-last-month.-The-nurse-determines-that-the-client-has-been-
noncompliant-with-the-diet,-based-on-which-report-from-the-24hr-diet-recall?---ans-✔✔1.-
Snack-of-potato-chips-&-diet-soda
2.-Lunch-of-tuna,-carrots,-fruit-&-coffee
3.-Breakfast-of-eggs,-bacon,-toast-&-coffee
4.-Bedtime-snack-of-crackers-&-milk
What-intervention-should-the-nurse-include-in-the-care-plan-for-a-client-who-is-being-
treated-with-an-Unna's-paste-boot-for-leg-ulcers-due-to-chronic-venous-insufficiency?---
ans-✔✔Check-capillary-refill-of-toes-on-lower-extremity-with-Unna's-paste-boot-
Rationale:-Boot-becomes-rigid-after-it-dries,-so-it-is-important-to-check-distally-for-
adequate-circulation.-No-bandage-should-be-put-under-it.-Should-be-applied-from-foot-&-
wrapped-towards-knee.-Acts-as-a-sterile-dressing-&-should-not-be-removed-q8h.-Weekly-
removal-is-reasonable.
EXAM #1
A-35y/o-client-with-cancer-refuses-to-allow-a-nurse-to-insert-an-IV-for-scheduled-chemo-&-
states-that-she's-ready-to-go-home-to-die.-What-intervention-should-the-nurse-initiate?---
ans-✔✔Evaluate-the-client's-mental-status-for-competence-to-refuse-treatment
Rationale:-Competent-clients-have-the-right-to-refuse-treatment.-The-nurse-cannot-
document-until-the-HCP-is-notified-of-the-patient's-wishes-&-a-d/c-RX-is-obtained.-
Advance-directives-&-DNR-are-not-necessary-for-competent-client-to-refuse-care.
A-client-with-chronic-renal-disease-is-admitted-to-the-hospital-for-evaluation-prior-to-a-
surgical-procedure.-Which-laboratory-test-indicates-client's-protein-status-for-the-longest-
length-of-time?---ans-✔✔Serum-albumin
Rationale:-Serum-albumin-has-a-long-half-life.
What-client-statement-indicates-to-the-nurse-that-the-client-requires-assistance-with-
bathing?---ans-✔✔"I-don't-understand-why-I'm-so-weak-&-tired."
How-should-the-nurse-handle-linens-that-are-soiled-with-incontinent-feces?---ans-
✔✔Place-the-soiled-linens-in-a-pillow-case-&-deposit-them-in-the-dirty-linen-hamper
When-caring-for-an-immobile-client,-what-nursing-diagnosis-has-the-highest-priority?---
ans-✔✔Impaired-gas-exchange
The-nurse-assesses-an-immobile,-elderly-male-client-&-determines-that-his-blood-
pressure-is-138/60,-his-temperature-is-95.8F-&-his-output-is-100-mL-of-concentrated-urine-
during-the-last-hour.-He-has-wet-sounding-lungs-&-increased-respiratory-secretions.-
Based-on-these-assessment-findings-,-what-nursing-action-is-most-important-for-the-nurse-
to-implement?---ans-✔✔Turn-the-client-q2h
Rationale:-It-will-help-move-&-drain-respiratory-secretions-&-prevent-pneumonia-from-
occurring.
The-home-health-nurse-visits-an-elderly-female-client-who-had-a-brain-attack-3-months-
ago-&-is-now-able-to-ambulate-with-the-assistance-of-a-quad-cane.-Which-assessment-
, finding-has-the-greatest-implications-for-this-client's-care?---ans-✔✔The-nurse-notes-
there-are-numerous-scatter-rugs-throughout-the-house
The-nurse-removes-the-dressing-on-a-client's-heel-that-is-cover-a-pressure-sore-1"-in-
diameter-&-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?---ans-✔✔One-
inch-pressure-sore-draining-serous-fluid
Medication-is-prescribed-to-be-given-QID.-What-schedule-should-the-nurse-use-to-
administer-this-Rx?---ans-✔✔0800,-1200,-1600,-2000
The-nurse-working-in-the-ED-is-assessing-4-clients'-ability-to-tolerate-pain.-Which-client-is-
likely-to-tolerate-a-higher-level-of-pain?---ans-✔✔1-55y/o-woman-who-has-had-moderate-
low-back-pain-for-3-months
Rationale:-Experiences-with-the-same-type-of-pain-that-has-successfully-been-relieved-
makes-it-easier-for-the-client-to-interpret-the-pain-sensation-and,-as-a-result,-the-client-is-
better-prepared-to-take-steps-to-relieve-the-pain.-All-other-clients-are-having-new-
experiences-with-pain.
A-4y/o-boy-who-is-scheduled-for-a-tonsillectomy-&-adenoidectomy-asks-the-nurse,-"Will-it-
hurt-to-have-my-tonsils-&-adenoids-taken-out?"-Which-response-is-best-for-the-nurse-to-
provide?---ans-✔✔"It-may-hurt,-but-we'll-give-you-medicine-to-help-you-feel-better."
A-low-sodium,-low-protein-diet-is-prescribed-for-a-45y/o-client-with-renal-insufficiency-&-
HTN,-who-gained-3lbs-in-the-last-month.-The-nurse-determines-that-the-client-has-been-
noncompliant-with-the-diet,-based-on-which-report-from-the-24hr-diet-recall?---ans-✔✔1.-
Snack-of-potato-chips-&-diet-soda
2.-Lunch-of-tuna,-carrots,-fruit-&-coffee
3.-Breakfast-of-eggs,-bacon,-toast-&-coffee
4.-Bedtime-snack-of-crackers-&-milk
What-intervention-should-the-nurse-include-in-the-care-plan-for-a-client-who-is-being-
treated-with-an-Unna's-paste-boot-for-leg-ulcers-due-to-chronic-venous-insufficiency?---
ans-✔✔Check-capillary-refill-of-toes-on-lower-extremity-with-Unna's-paste-boot-
Rationale:-Boot-becomes-rigid-after-it-dries,-so-it-is-important-to-check-distally-for-
adequate-circulation.-No-bandage-should-be-put-under-it.-Should-be-applied-from-foot-&-
wrapped-towards-knee.-Acts-as-a-sterile-dressing-&-should-not-be-removed-q8h.-Weekly-
removal-is-reasonable.
