HESI FUNDAMENTAL COMPLETE
QUESTIONS AND ANSWERS GRADED A+
◉ 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.
Answer: C. Report the results of the vital signs to the nurse.
(Interpretation of the vital signs is the responsibility of the nurse,
so the UAP should report vital sign measurements of 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.)
◉ Twenty minutes after beginning a heat application, the client
states that the heating pad no longer feels warm enough. What is
the best response by the nurse?
A. That means you have derived the maximum benefit, and the
heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat
from the site.
C. We will increase the temperature 5 degrees when the pad no
longer feels warm.
,D. The body's receptors adapt over time as they are exposed to
heat.
Answer: D. "The body's receptors adapt over time as they are
exposed to heat."
( (D) describes thermal adaptation, which occurs 20 to 30
minutes after heat application. (A and B) provide false
information. (C) is not based on knowledge of physiology and is
unsafe action that may harm the client.)
◉ When assessing a client with wrist restraints, the nurse
observes that the fingers on the right hand are blue. What action
should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
Answer: A. Loosen the right wrist restraint.
(The priority nursing action is to restore circulation by loosening
the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry
(B) measures saturation of hemoglobin with oxygen and is not
indicated in situations where the cyanosis is related to mechanical
compression-- the restraints.)
, ◉ An elderly client who requires frequent monitoring fell and
fractured a hip. Which nurse is at greatest risk for a malpractice
judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote
poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at
the time of the fall.
C. The nurse who transferred the client to the chair when the fall
occurred.
D. The charge nurse who completed rounds 30 minutes before the
fall occurred.
Answer: C. The nurse who transferred the client to the chair when
the fall occurred.
(The four elements of malpractice are: breach of duty owed,
failure to adhere to the recognized standard of care, direct
causation of injury, and evidence of actual injury. The hip fracture
is the actual injury and the standard of care was "frequent
monitoring." (C) implies the duty was owed and the injury
occurred while the nurse was in charge of the client's care. There
is no evidence of negligence in (A, B, and D). )
◉ The nurse observes an unlicensed assistive personnel (UAP)
taking a client's blood pressure with a cuff that is too small, but
the blood pressure reading obtained is within the client's usual
range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled
assessment.
B. Reassess the client's blood pressure using a larger cuff.
QUESTIONS AND ANSWERS GRADED A+
◉ 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.
Answer: C. Report the results of the vital signs to the nurse.
(Interpretation of the vital signs is the responsibility of the nurse,
so the UAP should report vital sign measurements of 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.)
◉ Twenty minutes after beginning a heat application, the client
states that the heating pad no longer feels warm enough. What is
the best response by the nurse?
A. That means you have derived the maximum benefit, and the
heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat
from the site.
C. We will increase the temperature 5 degrees when the pad no
longer feels warm.
,D. The body's receptors adapt over time as they are exposed to
heat.
Answer: D. "The body's receptors adapt over time as they are
exposed to heat."
( (D) describes thermal adaptation, which occurs 20 to 30
minutes after heat application. (A and B) provide false
information. (C) is not based on knowledge of physiology and is
unsafe action that may harm the client.)
◉ When assessing a client with wrist restraints, the nurse
observes that the fingers on the right hand are blue. What action
should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
Answer: A. Loosen the right wrist restraint.
(The priority nursing action is to restore circulation by loosening
the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry
(B) measures saturation of hemoglobin with oxygen and is not
indicated in situations where the cyanosis is related to mechanical
compression-- the restraints.)
, ◉ An elderly client who requires frequent monitoring fell and
fractured a hip. Which nurse is at greatest risk for a malpractice
judgement?
A. A nurse who worked the 7 to 3 shift at the hospital and wrote
poor nursing notes.
B. The nurse assigned to care for the client who was at lunch at
the time of the fall.
C. The nurse who transferred the client to the chair when the fall
occurred.
D. The charge nurse who completed rounds 30 minutes before the
fall occurred.
Answer: C. The nurse who transferred the client to the chair when
the fall occurred.
(The four elements of malpractice are: breach of duty owed,
failure to adhere to the recognized standard of care, direct
causation of injury, and evidence of actual injury. The hip fracture
is the actual injury and the standard of care was "frequent
monitoring." (C) implies the duty was owed and the injury
occurred while the nurse was in charge of the client's care. There
is no evidence of negligence in (A, B, and D). )
◉ The nurse observes an unlicensed assistive personnel (UAP)
taking a client's blood pressure with a cuff that is too small, but
the blood pressure reading obtained is within the client's usual
range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled
assessment.
B. Reassess the client's blood pressure using a larger cuff.
