FUNDAMENTAL HESI EVALUATION EXAMS
UPDATED QUESTIONS AND ANSWERS SURE A+
✔✔A nurse in the surgical intensive care unit is caring for a client with a large surgical
incision. The nurse reviews a list of vitamins and expects that which medication will be
prescribed because of its major role in wound healing?
1
Vitamin A (Aquasol A)
2
Cyanocobalamin (Cobex)
3
Phytonadione (Mephyton)
4
Ascorbic acid (Ascorbicap) - ✔✔4
Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the
maintenance and formation of collagen, the major protein of most connective tissues.
Vitamin A is important for the healing process; however, vitamin C is the priority
because it cements the ground substance of supportive tissue. Cyanocobalamin is a
vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous
system. Phytonadione is vitamin K, which plays a major role in blood coagulation.
,✔✔A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client
loses weight and develops a negative nitrogen balance. The nurse concludes that what
likely contributed to this client's weight loss?
1
Excessive carbohydrate intake
2
Lack of protein supplementation
3
Insufficient intake of water-soluble vitamins
4
Increased concentration of electrolytes in cells - ✔✔2
An infusion of dextrose in water does not provide proteins required for tissue growth,
repair, and maintenance; therefore, tissue breakdown occurs to supply the essential
amino acids. Each liter provides approximately 170 calories, which is insufficient to
meet minimal energy requirements; tissue breakdown will result. Weight loss is caused
by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5%
dextrose in water may decrease electrolyte concentration.
✔✔A client has undergone a subtotal thyroidectomy. The client is being transferred from
the post anesthesia care unit/recovery area to the inpatient nursing unit. What
emergency equipment is most important for the nurse to have available for this client?
1
A defibrillator
2
An IV infusion pump
3
A tracheostomy tray
4
An electrocardiogram (ECG) monitor - ✔✔3
The client who has undergone a subtotal thyroidectomy is at high risk for airway
occlusion resulting from postoperative edema. With this in mind, emergency airway
equipment such as a tracheostomy set and intubation supplies should be immediately
available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram
(ECG) monitor are all equipment items that should be available to all postoperative
clients.
✔✔The nurse reviews a medical record and is concerned that the client may develop
hyperkalemia. Which disease increases the risk of hyperkalemia?
1
Crohn's
2
Cushing's
3
End-stage renal
4
Gastroesophageal reflux
,. - ✔✔3
One of the kidneys' functions is to eliminate potassium from the body; diseases of the
kidneys often interfere with this function, and hyperkalemia may develop, necessitating
dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients
with Cushing's disease will retain sodium and excrete potassium. Clients with
gastroesophageal reflux disease are prone to vomiting that may lead to sodium and
chloride loss with minimal loss of potassium
✔✔A nurse assesses a client's serum electrolyte levels in the laboratory report. What
electrolyte in intracellular fluid should the nurse consider most important?
1
Sodium
2
Calcium
3
Chloride
4
Potassium - ✔✔4
The concentration of potassium is greater inside the cell and is important in establishing
a membrane potential, a critical factor in the cell's ability to function. Sodium is the most
abundant cation of the extracellular compartment, not the intracellular compartment.
Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth
and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not
intracellular, anion.
✔✔What is the maximum length of time a nurse should allow an intravenous (IV) bag of
solution to infuse?
1
6 hours
2
12 hours
3
18 hours
4
24 hours - ✔✔4
After 24 hours there is increased risk for contamination of the solution and the bag
should be changed. It is unnecessary to change the bag any less often.
✔✔An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5%
dextrose in water is to be administered over a 20-minute period. The tubing has a drop
factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to
run? Record the answer using a whole number. ______ gtts/min
Solve the problem by using the following formula: Drops per minute = total number of
drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes =
= 37.5. Round the answer to 38 drops per minute. - ✔✔38
, Solve the problem by using the following formula: Drops per minute = total number of
drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes =
= 37.5. Round the answer to 38 drops per minute
✔✔The nurse manager is planning to assign an unlicensed assistive personnel (UAP)
to care for clients. What care can be delegated on a medical-surgical unit to a UAP?
Select all that apply.
Correct 1
Performing a bed bath for a client on bed rest
2
Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3)
3
Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered
Correct 4
Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
5
Assessing the wound integrity of a client recovering from an abdominal laparotomy -
✔✔1,4
Performing a bed bath for a client on bed rest is within the scope of practice of the UAP.
Assisting a client who has PCA to the bathroom does not require professional nursing
judgment and is within the job description of the UAP. Evaluating human responses to
medications requires the expertise of a licensed professional nurse. Obtaining an apical
pulse rate requires a professional nursing judgment to determine whether or not the
medication should be administered. Evaluating human responses to health care
interventions requires the expertise of a licensed professional nurse.
✔✔A client has an anaphylactic reaction after receiving intravenous penicillin. What
does the nurse conclude is the cause of this reaction?
1
An acquired atopic sensitization occurred.
2
There was passive immunity to the penicillin allergen.
3
Antibodies to penicillin developed after a previous exposure.
4
Potent antibodies were produced when the infusion was instituted - ✔✔3
Hypersensitivity results from the production of antibodies in response to exposure to
certain foreign substances (allergens). Earlier exposure is necessary for the
development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever
and asthma are atopic conditions. It is an active, not passive, immune response.
Antibodies developed when there was a previous, not current, exposure to penicillin.
✔✔A nurse is providing care to a client eight hours after the client had surgery to correct
an upper urinary tract obstruction. Which assessment finding should the nurse report to
the surgeon?
1
UPDATED QUESTIONS AND ANSWERS SURE A+
✔✔A nurse in the surgical intensive care unit is caring for a client with a large surgical
incision. The nurse reviews a list of vitamins and expects that which medication will be
prescribed because of its major role in wound healing?
1
Vitamin A (Aquasol A)
2
Cyanocobalamin (Cobex)
3
Phytonadione (Mephyton)
4
Ascorbic acid (Ascorbicap) - ✔✔4
Vitamin C (ascorbic acid) plays a major role in wound healing . It is necessary for the
maintenance and formation of collagen, the major protein of most connective tissues.
Vitamin A is important for the healing process; however, vitamin C is the priority
because it cements the ground substance of supportive tissue. Cyanocobalamin is a
vitamin B12 preparation needed for red blood cell synthesis and a healthy nervous
system. Phytonadione is vitamin K, which plays a major role in blood coagulation.
,✔✔A client is receiving an intravenous (IV) infusion of 5% dextrose in water. The client
loses weight and develops a negative nitrogen balance. The nurse concludes that what
likely contributed to this client's weight loss?
1
Excessive carbohydrate intake
2
Lack of protein supplementation
3
Insufficient intake of water-soluble vitamins
4
Increased concentration of electrolytes in cells - ✔✔2
An infusion of dextrose in water does not provide proteins required for tissue growth,
repair, and maintenance; therefore, tissue breakdown occurs to supply the essential
amino acids. Each liter provides approximately 170 calories, which is insufficient to
meet minimal energy requirements; tissue breakdown will result. Weight loss is caused
by insufficient nutrient intake; vitamins do not prevent weight loss. An infusion of 5%
dextrose in water may decrease electrolyte concentration.
✔✔A client has undergone a subtotal thyroidectomy. The client is being transferred from
the post anesthesia care unit/recovery area to the inpatient nursing unit. What
emergency equipment is most important for the nurse to have available for this client?
1
A defibrillator
2
An IV infusion pump
3
A tracheostomy tray
4
An electrocardiogram (ECG) monitor - ✔✔3
The client who has undergone a subtotal thyroidectomy is at high risk for airway
occlusion resulting from postoperative edema. With this in mind, emergency airway
equipment such as a tracheostomy set and intubation supplies should be immediately
available to the client. A defibrillator, an IV infusion pump, and an electrocardiogram
(ECG) monitor are all equipment items that should be available to all postoperative
clients.
✔✔The nurse reviews a medical record and is concerned that the client may develop
hyperkalemia. Which disease increases the risk of hyperkalemia?
1
Crohn's
2
Cushing's
3
End-stage renal
4
Gastroesophageal reflux
,. - ✔✔3
One of the kidneys' functions is to eliminate potassium from the body; diseases of the
kidneys often interfere with this function, and hyperkalemia may develop, necessitating
dialysis. Clients with Crohn's disease have diarrhea, resulting in potassium loss. Clients
with Cushing's disease will retain sodium and excrete potassium. Clients with
gastroesophageal reflux disease are prone to vomiting that may lead to sodium and
chloride loss with minimal loss of potassium
✔✔A nurse assesses a client's serum electrolyte levels in the laboratory report. What
electrolyte in intracellular fluid should the nurse consider most important?
1
Sodium
2
Calcium
3
Chloride
4
Potassium - ✔✔4
The concentration of potassium is greater inside the cell and is important in establishing
a membrane potential, a critical factor in the cell's ability to function. Sodium is the most
abundant cation of the extracellular compartment, not the intracellular compartment.
Calcium is the most abundant electrolyte in the body; 99% is concentrated in the teeth
and bones, and only 1% is available for bodily functions. Chloride is an extracellular, not
intracellular, anion.
✔✔What is the maximum length of time a nurse should allow an intravenous (IV) bag of
solution to infuse?
1
6 hours
2
12 hours
3
18 hours
4
24 hours - ✔✔4
After 24 hours there is increased risk for contamination of the solution and the bag
should be changed. It is unnecessary to change the bag any less often.
✔✔An intravenous piggyback (IVPB) of cefazolin (Kefzol) 500 mg in 50 mL of 5%
dextrose in water is to be administered over a 20-minute period. The tubing has a drop
factor of 15 drops/mL. At what rate per minute should the nurse regulate the infusion to
run? Record the answer using a whole number. ______ gtts/min
Solve the problem by using the following formula: Drops per minute = total number of
drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes =
= 37.5. Round the answer to 38 drops per minute. - ✔✔38
, Solve the problem by using the following formula: Drops per minute = total number of
drops / total time in minutes Drops per minute = 50 mL x 15 (drop factor) / 20 mintes =
= 37.5. Round the answer to 38 drops per minute
✔✔The nurse manager is planning to assign an unlicensed assistive personnel (UAP)
to care for clients. What care can be delegated on a medical-surgical unit to a UAP?
Select all that apply.
Correct 1
Performing a bed bath for a client on bed rest
2
Evaluating the effectiveness of acetaminophen and codeine (Tylenol #3)
3
Obtaining an apical pulse rate before oral digoxin (Lanoxin) is administered
Correct 4
Assisting a client who has patient-controlled analgesia (PCA) to the bathroom
5
Assessing the wound integrity of a client recovering from an abdominal laparotomy -
✔✔1,4
Performing a bed bath for a client on bed rest is within the scope of practice of the UAP.
Assisting a client who has PCA to the bathroom does not require professional nursing
judgment and is within the job description of the UAP. Evaluating human responses to
medications requires the expertise of a licensed professional nurse. Obtaining an apical
pulse rate requires a professional nursing judgment to determine whether or not the
medication should be administered. Evaluating human responses to health care
interventions requires the expertise of a licensed professional nurse.
✔✔A client has an anaphylactic reaction after receiving intravenous penicillin. What
does the nurse conclude is the cause of this reaction?
1
An acquired atopic sensitization occurred.
2
There was passive immunity to the penicillin allergen.
3
Antibodies to penicillin developed after a previous exposure.
4
Potent antibodies were produced when the infusion was instituted - ✔✔3
Hypersensitivity results from the production of antibodies in response to exposure to
certain foreign substances (allergens). Earlier exposure is necessary for the
development of these antibodies. This is not a sensitivity reaction to penicillin; hay fever
and asthma are atopic conditions. It is an active, not passive, immune response.
Antibodies developed when there was a previous, not current, exposure to penicillin.
✔✔A nurse is providing care to a client eight hours after the client had surgery to correct
an upper urinary tract obstruction. Which assessment finding should the nurse report to
the surgeon?
1
