HESI FUNDAMENTAL ACTUAL SCRIPT
WITH 100 PERCENT CORRECT ANSWERS
◉ The nurse is preparing to initiate parenteral nutrition (PN) for
a client. What actions will the nurse consider when administering
PN? (Select all that apply.)
A.
Remove the PN from the refrigerator 30 minutes before infusing.
B.
Have a second nurse double check the PN before connecting the
solution.
C.
Have a second IV line in place for administering IV medications.
D.
Assure the infusion time for the PN does not exceed 24 hours.
E.
Tell the client a feeling of being full should occur with PN.
F.
Return amber and cloudy solutions of PN to the pharmacy.
Answer: A, D, F
Rationale: There are no issues with antibody incompatibility with
PN, so there is no need to double check the PN, or start a second
IV line. PN is administered through the venous system and does
not satiate the client. The remaining selections are true about the
administration of PN.
,◉ The nurse is preparing to insert an IV, and cap off the IV with an
intermittent infusion devise for an 80-year-old who is prescribed
IV antibiotics every 8 hours. The client is taking po fluids well.
What supplies will the nurse take into the room for this
procedure? (Select all that apply.)
A.
A 16 gauge IV catheter
B.
Normal saline in a 10 mL syringe
C.
Clear plastic sterile bandage
D.
Skin preparation antiseptic swab
E.
1000 mL bag of normal saline
Answer: B, C, D
Rationale: Items not needed to insert an IV for intermittent
antibiotic therapy for an 80-year-old are a 16 gauge intracath; the
intracath is too large. Large bore intracaths are for rapid
infusions. A small bag of NS, e.g. 250 mL, will be needed to flush
the line. The remaining items are needed to start an IV.
◉ The nurse is instructing a client with cholecystitis regarding
diet choices. Which meal best meets the dietary needs of this
client?
,A.
Steak, baked beans, and a salad
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake
Answer: B
Rationale: Clients with cholecystitis (inflammation of the
gallbladder) should follow a low-fat diet, such as option B. Option
A is a high-protein diet, and options C and D contain high-fat
foods, which are contraindicated for this client.
◉ A 65-year-old client who attends an adult daycare program and
is wheelchair mobile has redness in the sacral area. Which
instruction is most important for the nurse to provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair."
, Answer: B
Rationale: The most important teaching is to change positions
frequently because pressure is the most significant factor related
to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce
further risk. Option D is an intervention of last resort because this
will be very expensive for the client.
◉ Which nonverbal action should the nurse implement to
demonstrate active listening?
A.
Sit facing the client.
B.
Cross arms and legs.
C.
Avoid eye contact.
D.
Lean back in the chair.
Answer: A
Rationale: Active listening is conveyed using attentive verbal and
nonverbal communication techniques. To facilitate therapeutic
communication and attentiveness, the nurse should sit facing the
client, which lets the client know that the nurse is there to listen.
Active listening skills include postures that are open to the client,
such as keeping the arms open and relaxed, not option B, and
leaning toward the client, not option D. To communicate
WITH 100 PERCENT CORRECT ANSWERS
◉ The nurse is preparing to initiate parenteral nutrition (PN) for
a client. What actions will the nurse consider when administering
PN? (Select all that apply.)
A.
Remove the PN from the refrigerator 30 minutes before infusing.
B.
Have a second nurse double check the PN before connecting the
solution.
C.
Have a second IV line in place for administering IV medications.
D.
Assure the infusion time for the PN does not exceed 24 hours.
E.
Tell the client a feeling of being full should occur with PN.
F.
Return amber and cloudy solutions of PN to the pharmacy.
Answer: A, D, F
Rationale: There are no issues with antibody incompatibility with
PN, so there is no need to double check the PN, or start a second
IV line. PN is administered through the venous system and does
not satiate the client. The remaining selections are true about the
administration of PN.
,◉ The nurse is preparing to insert an IV, and cap off the IV with an
intermittent infusion devise for an 80-year-old who is prescribed
IV antibiotics every 8 hours. The client is taking po fluids well.
What supplies will the nurse take into the room for this
procedure? (Select all that apply.)
A.
A 16 gauge IV catheter
B.
Normal saline in a 10 mL syringe
C.
Clear plastic sterile bandage
D.
Skin preparation antiseptic swab
E.
1000 mL bag of normal saline
Answer: B, C, D
Rationale: Items not needed to insert an IV for intermittent
antibiotic therapy for an 80-year-old are a 16 gauge intracath; the
intracath is too large. Large bore intracaths are for rapid
infusions. A small bag of NS, e.g. 250 mL, will be needed to flush
the line. The remaining items are needed to start an IV.
◉ The nurse is instructing a client with cholecystitis regarding
diet choices. Which meal best meets the dietary needs of this
client?
,A.
Steak, baked beans, and a salad
B.
Broiled fish, green beans, and an apple
C.
Pork chops, macaroni and cheese, and grapes
D.
Avocado salad, milk, and angel food cake
Answer: B
Rationale: Clients with cholecystitis (inflammation of the
gallbladder) should follow a low-fat diet, such as option B. Option
A is a high-protein diet, and options C and D contain high-fat
foods, which are contraindicated for this client.
◉ A 65-year-old client who attends an adult daycare program and
is wheelchair mobile has redness in the sacral area. Which
instruction is most important for the nurse to provide?
A.
"Take a vitamin supplement tablet once a day."
B.
"Change positions in the chair frequently"
C.
"Increase daily intake of water or other oral fluids."
D.
"Purchase a newer model wheelchair."
, Answer: B
Rationale: The most important teaching is to change positions
frequently because pressure is the most significant factor related
to the development of pressure ulcers. Increased vitamin and fluid
intake may also be beneficial and promote healing and reduce
further risk. Option D is an intervention of last resort because this
will be very expensive for the client.
◉ Which nonverbal action should the nurse implement to
demonstrate active listening?
A.
Sit facing the client.
B.
Cross arms and legs.
C.
Avoid eye contact.
D.
Lean back in the chair.
Answer: A
Rationale: Active listening is conveyed using attentive verbal and
nonverbal communication techniques. To facilitate therapeutic
communication and attentiveness, the nurse should sit facing the
client, which lets the client know that the nurse is there to listen.
Active listening skills include postures that are open to the client,
such as keeping the arms open and relaxed, not option B, and
leaning toward the client, not option D. To communicate
