HESI RN FUNDAMENTALS REVIEW EXAMS UPDATED
QUESTIONS AND ANSWERS SURE A+
✔✔Examination of a client complaining of itching on his right arm reveals a rash made
up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How
should the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ✔✔B.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. (Macules are
localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance (B) rather than simply naming
the condition. (A) identifies vesicles-- fluid filled blisters--an incorrect description given
the symptoms listed. (C) identifies papule-- solid elevated lesions, again not correctly
identifying the symptoms. (D) identifies petechiae-- pinpoint red to purple skin
discolorations that do not itch, again an incorrect identification.)
✔✔At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. What would be an appropriate response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery,
the better you will feel."
, B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her
experiences with you." - ✔✔C. "It is OK if you don't want to talk about your surgery. I will
be available when you are ready."
( (C) displays sensitivity and understanding without judging the client. (A) is judgmental
in that it is telling the client how she feels and is also insensitive. (B) would give the
client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support if not offered, this response could be
interpreted as dismissing the client and avoiding the problem.)
✔✔The nurse is evaluating a client learning about a low-sodium diet. Selection of which
meal would indicate to the nurse that this client understands the dietary restrictions? -
✔✔Skim milk, turkey salad, roll, and vanilla ice cream
✔✔The nurse prepares a 1000 mL IV of 5% dextrose and water to be infused over 8
hours. The infusion set delivers 10 drops per milliliter . The nurse should regulate the IV
to administer approximately how many drops per minute? - ✔✔21
✔✔An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the best
client position for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sim's
D. Supine - ✔✔B. Fowler's
(The client should be positioned in a semi-setting (B) position during feeding to
decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to
placement by a percutaneous endoscopic gastronomy procedure, is inserted directly
into the stomach through an incision in the abdomen for long-term administration of
nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on
the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk
for aspiration.)
✔✔Which action is the most important to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. - ✔✔C. Keep gloved hands above the
elbows. (Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the glove on the
dominant hand first, it is not necessary to ensure asepsis (D).)
QUESTIONS AND ANSWERS SURE A+
✔✔Examination of a client complaining of itching on his right arm reveals a rash made
up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How
should the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ✔✔B.
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. (Macules are
localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance (B) rather than simply naming
the condition. (A) identifies vesicles-- fluid filled blisters--an incorrect description given
the symptoms listed. (C) identifies papule-- solid elevated lesions, again not correctly
identifying the symptoms. (D) identifies petechiae-- pinpoint red to purple skin
discolorations that do not itch, again an incorrect identification.)
✔✔At the time of the first dressing change, the client refuses to look at her mastectomy
incision. The nurse tells the client that the incision is healing well, but the client refuses
to talk about it. What would be an appropriate response to this client's silence?
A. "It is normal to feel angry and depressed, but the sooner you deal with this surgery,
the better you will feel."
, B. "Looking at your incision can be frightening, but facing this fear is a necessary part of
your recovery."
C. "It is OK if you don't want to talk about your surgery. I will be available when you are
ready."
D. "I will ask a woman who has had a mastectomy to come by and share her
experiences with you." - ✔✔C. "It is OK if you don't want to talk about your surgery. I will
be available when you are ready."
( (C) displays sensitivity and understanding without judging the client. (A) is judgmental
in that it is telling the client how she feels and is also insensitive. (B) would give the
client a chance to talk, but is also demanding and demeaning. (D) displays a positive
action, but, because the nurse's personal support if not offered, this response could be
interpreted as dismissing the client and avoiding the problem.)
✔✔The nurse is evaluating a client learning about a low-sodium diet. Selection of which
meal would indicate to the nurse that this client understands the dietary restrictions? -
✔✔Skim milk, turkey salad, roll, and vanilla ice cream
✔✔The nurse prepares a 1000 mL IV of 5% dextrose and water to be infused over 8
hours. The infusion set delivers 10 drops per milliliter . The nurse should regulate the IV
to administer approximately how many drops per minute? - ✔✔21
✔✔An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the best
client position for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sim's
D. Supine - ✔✔B. Fowler's
(The client should be positioned in a semi-setting (B) position during feeding to
decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to
placement by a percutaneous endoscopic gastronomy procedure, is inserted directly
into the stomach through an incision in the abdomen for long-term administration of
nutrition and hydration in the debilitated client. In (A and/or C), the client is placed on
the abdomen, an unsafe position for feeding. Placing the client in (D) increases the risk
for aspiration.)
✔✔Which action is the most important to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. - ✔✔C. Keep gloved hands above the
elbows. (Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the glove on the
dominant hand first, it is not necessary to ensure asepsis (D).)
