HESI Fundamental Test Bank - Examination Complete
Questions and Detailed Solutions
Latest Update This Year Just Released
Question 1: A client has a nursing diagnosis of Altered sleep
patterns related to nocturia. Which client instruction is important
for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill.
Answer:
ANSWER: A Rationale: Nocturia is urination during the night. Option A is helpful to
decrease the production of urine, thus decreasing the need to void at night. Option B
helps prevent bladder infections. Option C may promote sleep, but the fluid will
contribute to nocturia. Option D may result in urinary incontinence if the client is
sedated and does not awaken to void. When performing sterile wound care in the
acute care setting, the nurse obtains a bottle of normal saline from the bedside table
that i
Question 2: is urination during the night. Option A is helpful to
decrease the production of urine, thus decreasing the need to void
at night. Option B helps prevent bladder infections. Option C may
promote sleep, but the fluid will contribute to nocturia. Option D
may result in urinary incontinence if the client is sedated and does
not awaken to void. When performing sterile wound care in the
acute care setting, the nurse obtains a bottle of normal saline from
the bedside table that is labeled "opened" and dated 48 hours prior
to the current date. Which is the best action for the nurse to take?
A. Use the normal saline solution once more and then discard.
B. Obtain a new sterile syringe to draw up the labeled saline solution.
C. Use the saline solution and then relabel the bottle with the current date.
D. Discard the saline solution and obtain a new unopened bottle.
,Answer:
ANSWER: D Rationale: Solutions labeled as opened within 24 hours may be used for
clean procedures, but only newly opened solutions are considered sterile. This
solution is not newly opened and is out of date, so it should be discarded. Options A,
B, and C describe incorrect procedures. UU0 The nurse teaches the use of a gait belt
to a male caregiver whose wife has right-sided weakness and needs assistance with
ambulation. The caregiver performs a return demonstration of the skill. Which
observation indi
Question 3: ned bottle. - D Rationale: Solutions labeled as opened
within 24 hours may be used for clean procedures, but only newly
opened solutions are considered sterile. This solution is not newly
opened and is out of date, so it should be discarded. Options A, B,
and C describe incorrect procedures. UU0 The nurse teaches the
use of a gait belt to a male caregiver whose wife has right-sided
weakness and needs assistance with ambulation. The caregiver
performs a return demonstration of the skill. Which observation
indicates that the caregiver has learned how to perform this
procedure correctly?
A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt
if any evidence of weakness is observed.
B. Standing on his wife's weak side, the caregiver provides security by holding
the gait belt from the back.
C. Standing behind his wife, the caregiver provides balance by holding both
sides of the gait belt.
D. Standing slightly in front and to the right of his wife, the caregiver guides her
forward by gently pulling on the gait belt.
Answer:
ANSWER: B
Rationale: Rationale: His wife is most likely to lean toward the weak side and needs extra
support on that side and from the back to prevent falling. Options A, C, and D provide less
security for her. Which nursing diagnosis has the highest priority when planning care for a
client with an indwelling urinary catheter
,Question 4: Rationale: His wife is most likely to lean toward the
weak side and needs extra support on that side and from the back
to prevent falling. Options A, C, and D provide less security for her.
Which nursing diagnosis has the highest priority when planning
care for a client with an indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection
Answer:
ANSWER: D Rationale: Indwelling urinary catheters are a major source of infection.
Options A and B are both problems that may require an indwelling catheter. Option C
is not affected by an indwelling catheter. Based on the nursing diagnosis of risk for
infection, which intervention is best for the nurse to implement when providing care
for an older incontinent client
Question 5: A. Self-care deficit B. Functional incontinence C. Fluid
volume deficit D. High risk for infection - D Rationale: Indwelling
urinary catheters are a major source of infection. Options A and B
are both problems that may require an indwelling catheter. Option
C is not affected by an indwelling catheter. Based on the nursing
diagnosis of risk for infection, which intervention is best for the
nurse to implement when providing care for an older incontinent
client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers.
Answer:
, ANSWER: A Rationale: The best action to decrease the risk of infection in vulnerable
clients is handwashing. Option B is not necessary unless the client has an infection.
Option C increases the risk of infection. Option D does not reduce the risk of
infection. When taking a client's blood pressure, the nurse is unable to distinguish
the point at which the first sound was heard. Which is the best action for the nurse to
take
Question 6: Maintain standard precautions. B. Initiate contact
isolation measures. C. Insert an indwelling urinary catheter. D.
Instruct client in the use of adult diapers. - A Rationale: The best
action to decrease the risk of infection in vulnerable clients is
handwashing. Option B is not necessary unless the client has an
infection. Option C increases the risk of infection. Option D does
not reduce the risk of infection. When taking a client's blood
pressure, the nurse is unable to distinguish the point at which the
first sound was heard. Which is the best action for the nurse to
take?
A. Deflate the cuff completely and immediately reattempt the reading.
B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds
before taking the second reading.
C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the
reading.
D. Document the exact level visualized on the sphygmomanometer where the
first fluctuation was seen.
Answer:
ANSWER: C Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to
return to the extremity so that an accurate reading can be obtained on that extremity
a second time. Option A could result in a falsely high reading. Option B reduces
circulation, causes pain, and could alter the reading. Option D is not an accurate
method of assessing blood pressure. A client's blood pressure reading is 156/94 mm
Hg. Which action should the nurse take first
Question 7: fore reattempting the reading. D. Document the exact
level visualized on the sphygmomanometer where the first
Questions and Detailed Solutions
Latest Update This Year Just Released
Question 1: A client has a nursing diagnosis of Altered sleep
patterns related to nocturia. Which client instruction is important
for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill.
Answer:
ANSWER: A Rationale: Nocturia is urination during the night. Option A is helpful to
decrease the production of urine, thus decreasing the need to void at night. Option B
helps prevent bladder infections. Option C may promote sleep, but the fluid will
contribute to nocturia. Option D may result in urinary incontinence if the client is
sedated and does not awaken to void. When performing sterile wound care in the
acute care setting, the nurse obtains a bottle of normal saline from the bedside table
that i
Question 2: is urination during the night. Option A is helpful to
decrease the production of urine, thus decreasing the need to void
at night. Option B helps prevent bladder infections. Option C may
promote sleep, but the fluid will contribute to nocturia. Option D
may result in urinary incontinence if the client is sedated and does
not awaken to void. When performing sterile wound care in the
acute care setting, the nurse obtains a bottle of normal saline from
the bedside table that is labeled "opened" and dated 48 hours prior
to the current date. Which is the best action for the nurse to take?
A. Use the normal saline solution once more and then discard.
B. Obtain a new sterile syringe to draw up the labeled saline solution.
C. Use the saline solution and then relabel the bottle with the current date.
D. Discard the saline solution and obtain a new unopened bottle.
,Answer:
ANSWER: D Rationale: Solutions labeled as opened within 24 hours may be used for
clean procedures, but only newly opened solutions are considered sterile. This
solution is not newly opened and is out of date, so it should be discarded. Options A,
B, and C describe incorrect procedures. UU0 The nurse teaches the use of a gait belt
to a male caregiver whose wife has right-sided weakness and needs assistance with
ambulation. The caregiver performs a return demonstration of the skill. Which
observation indi
Question 3: ned bottle. - D Rationale: Solutions labeled as opened
within 24 hours may be used for clean procedures, but only newly
opened solutions are considered sterile. This solution is not newly
opened and is out of date, so it should be discarded. Options A, B,
and C describe incorrect procedures. UU0 The nurse teaches the
use of a gait belt to a male caregiver whose wife has right-sided
weakness and needs assistance with ambulation. The caregiver
performs a return demonstration of the skill. Which observation
indicates that the caregiver has learned how to perform this
procedure correctly?
A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt
if any evidence of weakness is observed.
B. Standing on his wife's weak side, the caregiver provides security by holding
the gait belt from the back.
C. Standing behind his wife, the caregiver provides balance by holding both
sides of the gait belt.
D. Standing slightly in front and to the right of his wife, the caregiver guides her
forward by gently pulling on the gait belt.
Answer:
ANSWER: B
Rationale: Rationale: His wife is most likely to lean toward the weak side and needs extra
support on that side and from the back to prevent falling. Options A, C, and D provide less
security for her. Which nursing diagnosis has the highest priority when planning care for a
client with an indwelling urinary catheter
,Question 4: Rationale: His wife is most likely to lean toward the
weak side and needs extra support on that side and from the back
to prevent falling. Options A, C, and D provide less security for her.
Which nursing diagnosis has the highest priority when planning
care for a client with an indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection
Answer:
ANSWER: D Rationale: Indwelling urinary catheters are a major source of infection.
Options A and B are both problems that may require an indwelling catheter. Option C
is not affected by an indwelling catheter. Based on the nursing diagnosis of risk for
infection, which intervention is best for the nurse to implement when providing care
for an older incontinent client
Question 5: A. Self-care deficit B. Functional incontinence C. Fluid
volume deficit D. High risk for infection - D Rationale: Indwelling
urinary catheters are a major source of infection. Options A and B
are both problems that may require an indwelling catheter. Option
C is not affected by an indwelling catheter. Based on the nursing
diagnosis of risk for infection, which intervention is best for the
nurse to implement when providing care for an older incontinent
client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers.
Answer:
, ANSWER: A Rationale: The best action to decrease the risk of infection in vulnerable
clients is handwashing. Option B is not necessary unless the client has an infection.
Option C increases the risk of infection. Option D does not reduce the risk of
infection. When taking a client's blood pressure, the nurse is unable to distinguish
the point at which the first sound was heard. Which is the best action for the nurse to
take
Question 6: Maintain standard precautions. B. Initiate contact
isolation measures. C. Insert an indwelling urinary catheter. D.
Instruct client in the use of adult diapers. - A Rationale: The best
action to decrease the risk of infection in vulnerable clients is
handwashing. Option B is not necessary unless the client has an
infection. Option C increases the risk of infection. Option D does
not reduce the risk of infection. When taking a client's blood
pressure, the nurse is unable to distinguish the point at which the
first sound was heard. Which is the best action for the nurse to
take?
A. Deflate the cuff completely and immediately reattempt the reading.
B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds
before taking the second reading.
C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the
reading.
D. Document the exact level visualized on the sphygmomanometer where the
first fluctuation was seen.
Answer:
ANSWER: C Rationale: Deflating the cuff for 30 to 60 seconds allows blood flow to
return to the extremity so that an accurate reading can be obtained on that extremity
a second time. Option A could result in a falsely high reading. Option B reduces
circulation, causes pain, and could alter the reading. Option D is not an accurate
method of assessing blood pressure. A client's blood pressure reading is 156/94 mm
Hg. Which action should the nurse take first
Question 7: fore reattempting the reading. D. Document the exact
level visualized on the sphygmomanometer where the first
