FUNDAMENTAL HESI UPDATED FINAL EXAM
QUESTIONS AND ANSWERS SURE A+
✔✔While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm
above and below the elbow. What nursing action should the nurse implement?
A) Acknowledge that she is supporting the arm correctly.
B) Encourage her to keep the joint covered to maintain warmth.
C) Reinforce the need to grip directly under the joint for better support.
D) Instruct her to grip directly over the joint for better motion. - ✔✔A) Acknowledge that
she is supporting the arm correctly
The wife is performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be uncovered (B)
while the rest of the body should remain covered for warmth and privacy. (C and D) do
not provide adequate support to the joint while still allowing for joint movement
✔✔A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first?
A) Sexual activity patterns.
B) Nutritional history.
,C) Leisure activities.
D) Financial stressors - ✔✔B) Nutritional history
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional
history (C) should be obtained first so that health teaching can be initiated if indicated.
(A and C) can be used for stress management. Though (D) can be a source of anxiety,
a nutritional history should be obtained first
✔✔The nurse is caring for a client who is receiving 24-hour total parenteral nutrition
(TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes
that the TPN solution has run out and the next TPN solution is not available. What
immediate action should the nurse take?
A) Infuse normal saline at a keep vein open rate.
B) Discontinue the IV and flush the port with heparin.
C) Infuse 10 percent dextrose and water at 54 ml/hr
D) Obtain a stat blood glucose level and notify the healthcare provider. - ✔✔C) Infuse
10 percent dextrose and water at 54 ml/hr
TPN is discontinued gradually to allow the client to adjust to decreased levels of
glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the
client from experiencing hypoglycemia until the next TPN solution is available. The
client could experience a hypoglycemic reaction if the current level of glucose (A) is not
maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat
blood glucose level (D) and the healthcare provider cannot do anything about this
situation
✔✔A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation
at the infusion site. The nurse observes erythema, swelling, and a red streak along the
vessel above the IV access site. Which action should the nurse take at this time?
A) Administer the medication more rapidly using the same IV site.
B) Initiate an alternate site for the IV infusion of the medication.
C) Notify the healthcare provider before administering the next dose.
D) Give the client a PRN dose of aspirin while the medication infuses - ✔✔B) Initiate an
alternate site for the IV infusion of the medication
A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating
the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site
should be initiated (B) before administering the next dose. Rapid administration (A) of
intravenous cephalosporins can potentiate vessel irritation and increase the risk of
thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin
has antiinflammatory actions, (D) is not indicated
✔✔The nurse is using a genogram while conducting a client's health assessment and
past medical history. What information should the genogram provide?
,A) Genetic and familial health disorders.
B) Chronic health problems.
C) Reason for seeking health care.
D) Undetected disorders. - ✔✔A) Genetic and familial health disorders
A genogram that is used during the health assessment process identifies genetic and
familial health disorders (A). It may not identify the client's chronic health problems (B),
so it is not a reason to seek health care (C). A genogram is not a diagnostic tool to
detect disorders (D), such as those based on pathological findings or DNA.
✔✔Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours.
How much heparin has the client received?
A) 11,000 units.
B) 13,000 units.
C) 15,000 units.
D) 17,000 units - ✔✔A) 11,000 units
✔✔A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A) demonstrates loss of remote memory.
B) exhibits expressive dysphasia.
C) has a diminished attention span.
D) is disoriented to place and time. - ✔✔D) is disoriented to place and time
The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The
client is able to express himself without difficulty (B), and does not demonstrate a
diminished attention span (C).
✔✔An obese male client discusses with the nurse his plans to begin a 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 beginning 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).
✔✔At the beginning of the shift, the nurse assesses a client who is admitted from the
post-anesthesia care unit (PACU). When should the nurse document the client's
findings?
A) At the beginning, middle, and end of the shift.
B) After client priorities are identified for the development of the nursing care plan.
C) At the end of the shift so full attention can be given to the client's needs.
D) Immediately after the assessments are completed - ✔✔D) Immediately after the
assessments are completed
Documentation should occur immediately after any component of the nursing process,
so assessments should be entered in the client's medical record as readily as findings
are obtained (D). (A, B, and C) do not address the concepts of legal recommendations
for information management and informatics.
✔✔The nurse assigns a UAP to obtain vital signs from a very anxious client. What
instructions should the nurse give the UAP?
A) Remain calm with the client and record abnormal results in the chart.
B) Notify the medication nurse immediately if the pulse or blood pressure is low.
C) Report the results of the vital signs to the nurse.
D) Reassure the client that the vital signs are normal. - ✔✔C) Report the results of the
vital signs to the nurse.
Interpretation of vital signs is the responsibility of the nurse, so the UAP should report
vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the
vital signs, which is beyond the scope of the UAP's authority
✔✔The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is
Lasix 20 mg/2 ml. How many milliliters should the nurse administer?
A) 1 ml.
B) 1.5 ml.
C) 1.75 ml.
D) 2 ml. - ✔✔B) 1.5 ml
QUESTIONS AND ANSWERS SURE A+
✔✔While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm
above and below the elbow. What nursing action should the nurse implement?
A) Acknowledge that she is supporting the arm correctly.
B) Encourage her to keep the joint covered to maintain warmth.
C) Reinforce the need to grip directly under the joint for better support.
D) Instruct her to grip directly over the joint for better motion. - ✔✔A) Acknowledge that
she is supporting the arm correctly
The wife is performing the passive ROM correctly, therefore the nurse should
acknowledge this fact (A). The joint that is being exercised should be uncovered (B)
while the rest of the body should remain covered for warmth and privacy. (C and D) do
not provide adequate support to the joint while still allowing for joint movement
✔✔A young mother of three children complains of increased anxiety during her annual
physical exam. What information should the nurse obtain first?
A) Sexual activity patterns.
B) Nutritional history.
,C) Leisure activities.
D) Financial stressors - ✔✔B) Nutritional history
Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional
history (C) should be obtained first so that health teaching can be initiated if indicated.
(A and C) can be used for stress management. Though (D) can be a source of anxiety,
a nutritional history should be obtained first
✔✔The nurse is caring for a client who is receiving 24-hour total parenteral nutrition
(TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes
that the TPN solution has run out and the next TPN solution is not available. What
immediate action should the nurse take?
A) Infuse normal saline at a keep vein open rate.
B) Discontinue the IV and flush the port with heparin.
C) Infuse 10 percent dextrose and water at 54 ml/hr
D) Obtain a stat blood glucose level and notify the healthcare provider. - ✔✔C) Infuse
10 percent dextrose and water at 54 ml/hr
TPN is discontinued gradually to allow the client to adjust to decreased levels of
glucose. Administering 10% dextrose in water at the prescribed rate (C) will keep the
client from experiencing hypoglycemia until the next TPN solution is available. The
client could experience a hypoglycemic reaction if the current level of glucose (A) is not
maintained or if the TPN is discontinued abruptly (B). There is no reason to obtain a stat
blood glucose level (D) and the healthcare provider cannot do anything about this
situation
✔✔A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation
at the infusion site. The nurse observes erythema, swelling, and a red streak along the
vessel above the IV access site. Which action should the nurse take at this time?
A) Administer the medication more rapidly using the same IV site.
B) Initiate an alternate site for the IV infusion of the medication.
C) Notify the healthcare provider before administering the next dose.
D) Give the client a PRN dose of aspirin while the medication infuses - ✔✔B) Initiate an
alternate site for the IV infusion of the medication
A cephalosporin antibiotic that is administered IV may cause vessel irritation. Rotating
the infusion site minimizes the risk of thrombophlebitis, so an alternate infusion site
should be initiated (B) before administering the next dose. Rapid administration (A) of
intravenous cephalosporins can potentiate vessel irritation and increase the risk of
thrombophlebitis. (C) is not necessary to initiate an alternative IV site. Although aspirin
has antiinflammatory actions, (D) is not indicated
✔✔The nurse is using a genogram while conducting a client's health assessment and
past medical history. What information should the genogram provide?
,A) Genetic and familial health disorders.
B) Chronic health problems.
C) Reason for seeking health care.
D) Undetected disorders. - ✔✔A) Genetic and familial health disorders
A genogram that is used during the health assessment process identifies genetic and
familial health disorders (A). It may not identify the client's chronic health problems (B),
so it is not a reason to seek health care (C). A genogram is not a diagnostic tool to
detect disorders (D), such as those based on pathological findings or DNA.
✔✔Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours.
How much heparin has the client received?
A) 11,000 units.
B) 13,000 units.
C) 15,000 units.
D) 17,000 units - ✔✔A) 11,000 units
✔✔A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A) demonstrates loss of remote memory.
B) exhibits expressive dysphasia.
C) has a diminished attention span.
D) is disoriented to place and time. - ✔✔D) is disoriented to place and time
The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The
client is able to express himself without difficulty (B), and does not demonstrate a
diminished attention span (C).
✔✔An obese male client discusses with the nurse his plans to begin a 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 beginning 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).
✔✔At the beginning of the shift, the nurse assesses a client who is admitted from the
post-anesthesia care unit (PACU). When should the nurse document the client's
findings?
A) At the beginning, middle, and end of the shift.
B) After client priorities are identified for the development of the nursing care plan.
C) At the end of the shift so full attention can be given to the client's needs.
D) Immediately after the assessments are completed - ✔✔D) Immediately after the
assessments are completed
Documentation should occur immediately after any component of the nursing process,
so assessments should be entered in the client's medical record as readily as findings
are obtained (D). (A, B, and C) do not address the concepts of legal recommendations
for information management and informatics.
✔✔The nurse assigns a UAP to obtain vital signs from a very anxious client. What
instructions should the nurse give the UAP?
A) Remain calm with the client and record abnormal results in the chart.
B) Notify the medication nurse immediately if the pulse or blood pressure is low.
C) Report the results of the vital signs to the nurse.
D) Reassure the client that the vital signs are normal. - ✔✔C) Report the results of the
vital signs to the nurse.
Interpretation of vital signs is the responsibility of the nurse, so the UAP should report
vital sign measurements to the nurse (C). (A, B, and D) require the UAP to interpret the
vital signs, which is beyond the scope of the UAP's authority
✔✔The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is
Lasix 20 mg/2 ml. How many milliliters should the nurse administer?
A) 1 ml.
B) 1.5 ml.
C) 1.75 ml.
D) 2 ml. - ✔✔B) 1.5 ml
