HESI FUNDAMENTAL PRACTICE EXAM
|CPMPLETE QUESTIONS, CORRECT
ANSWERS AND DETAILED
RATIONALES
In developing a plan of care for a client with dementia, the nurse
should remember that confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - ANS✔✔-B. often
follows relocation to new surroundings (Relocation (B) often
results in confusion among elderly clients-- moving is stressful for
anyone. (A) is stereotypical judgement. Stress in the elderly often
manifests itself as confusion, so (C) is wrong. Adequate sleep is
not a prevention (D) for confusion.)
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 - ANS✔✔-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?" - ANS✔✔-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. -
ANS✔✔-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 - ANS✔✔-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. - ANS✔✔-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? -
ANS✔✔-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? - ANS✔✔-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. - ANS✔✔-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 - ANS✔✔-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?
|CPMPLETE QUESTIONS, CORRECT
ANSWERS AND DETAILED
RATIONALES
In developing a plan of care for a client with dementia, the nurse
should remember that confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - ANS✔✔-B. often
follows relocation to new surroundings (Relocation (B) often
results in confusion among elderly clients-- moving is stressful for
anyone. (A) is stereotypical judgement. Stress in the elderly often
manifests itself as confusion, so (C) is wrong. Adequate sleep is
not a prevention (D) for confusion.)
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 - ANS✔✔-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?" - ANS✔✔-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. -
ANS✔✔-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 - ANS✔✔-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. - ANS✔✔-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? -
ANS✔✔-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? - ANS✔✔-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. - ANS✔✔-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 - ANS✔✔-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?
