Hesi Fundamentals Practice
1. Which drug does a nurse anticipate may be prescribed to produce
diuresis and inhibit formation of aqueous humor for a client with
glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide (Humorsol)
2. A client receiving steroid therapy states, "I have difficulty controlling my
temper which is so unlike me, and I don't know why this is happening."
What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being
experienced.
3. A client receiving steroid therapy states, "I have difficulty controlling my
temper which is so unlike me, and I don't know why this is happening."
What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being
experienced.
4. The nurse is caring for a client with a temperature of 104.5 degrees
Fahrenheit. The nurse applies a cooling blanket and administers an
antipyretic medication. The nurse explains that the rationale for these
interventions is to:
Promote equalization of osmotic pressures.
Prevent hypoxia associated with diaphoresis.
Promote integrity of intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
5. A health care provider prescribes 500 mg of an antibiotic intravenous
piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and
indicates that the addition of 2.5 mL of sterile water will yield 3 mL of
reconstituted solution. How many milliliters of the antibiotic should be
added to the 50 mL IVPB bag? Record your answer using one decimal
place. __ mL
1.5
1
,6. The nurse is caring for a non-ambulatory client with a reddened sacrum
that is unrelieved by repositioning. What nursing diagnosis should be
included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning
Impaired skin integrity, related to the effects of pressure and shearing force
7. A client has a pressure ulcer that is full thickness with necrosis into the
subcutaneous tissue down to the underlying fascia. The nurse should
document the assessment finding as which stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be
removed before the wound can be staged. A stage I pressure ulcer is defined as an
area of persistent redness with no break in skin integrity. A stage II pressure ulcer
is a partial-thickness wound with skin loss involving the epidermis, dermis, or both;
the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A
stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous
fat. Bone, tendon, and muscle are not exposed.
8. A client is being admitted for a total hip replacement. When is it
necessary for the nurse to ensure that a medication reconciliation is
completed? Select all that apply.
After reporting severe pain
On admission to the hospital
Upon entering the operating room
Before transfer to a rehabilitation facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client
is taking and comparing it to the health care provider's prescriptions on admission
or when there is a transfer to a different setting or service, or discharge. A change
in status does not require medication reconciliation. A medication reconciliation
should be completed long before entering the operating room. Total hip
replacement is elective surgery, and scheduling takes place before admission;
medication reconciliation takes place when the client is admitted.
9. A client is taking lithium sodium (Lithium). The nurse should notify the
health care provider for which of the following laboratory values?
White blood cell (WBC) count of 15,000 mm3
Negative protein in the urine
2
, Blood urea nitrogen (BUN) of 20 mg/dL
Prothrombin of 12.0 seconds
White cell counts can increase with this drug. The expected range of the WBC
count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin
are not necessary and these are normal values.
10. Often when a family member is dying, the client and the family are
at different stages of grieving. During which stage of a client's grieving is
the family likely to require more emotional nursing care than the client?
Anger
Denial
Depression
Acceptance
In the stage of acceptance, the client frequently detaches from the environment
and may become indifferent to family members. In addition, the family may take longer
to accept the inevitable death than does the client. Although the family may not
understand the anger, dealing with the resultant behavior may serve as a diversion.
Denial often is exhibited by the client and family members at the same time. During
depression, the family often is able to offer emotional support, which meets their needs.
11. The client asks the nurse to recommend foods that might be
included in a diet for diverticular disease. Which foods would be
appropriate to include in the teaching plan? Select all that apply.
Whole grains
Cooked fruit and vegetables
Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease the patient should avoid foods that may obstruct the
diverticuli. Therefore the fiber should be digestible, such as whole grains, and
cooked fruits and vegetables. Milk and eggs have no fiber content but are good
sources of protein. In clients with diverticular disease, nuts and seeds are
contraindicated as they may be retained and cause inflammation and infection,
which is known as diverticulitis. The client should also decrease intake of fats and
red meats.
12. A nurse is obtaining a health history from the newly admitted client
who has chronic pain in the knee. What should the nurse include in the
pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
3
1. Which drug does a nurse anticipate may be prescribed to produce
diuresis and inhibit formation of aqueous humor for a client with
glaucoma?
Chlorothiazide (Diuril)
Acetazolamide (Diamox)
Bendroflumethiazide (Naturetin)
Demecarium bromide (Humorsol)
2. A client receiving steroid therapy states, "I have difficulty controlling my
temper which is so unlike me, and I don't know why this is happening."
What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being
experienced.
3. A client receiving steroid therapy states, "I have difficulty controlling my
temper which is so unlike me, and I don't know why this is happening."
What is the nurse's best response?
Tell the client it is nothing to worry about.
Talk with the client further to identify the specific cause of the problem.
Instruct the client to attempt to avoid situations that cause irritation.
Interview the client to determine whether other mood swings are being
experienced.
4. The nurse is caring for a client with a temperature of 104.5 degrees
Fahrenheit. The nurse applies a cooling blanket and administers an
antipyretic medication. The nurse explains that the rationale for these
interventions is to:
Promote equalization of osmotic pressures.
Prevent hypoxia associated with diaphoresis.
Promote integrity of intracerebral neurons.
Reduce brain metabolism and limit hypoxia.
5. A health care provider prescribes 500 mg of an antibiotic intravenous
piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and
indicates that the addition of 2.5 mL of sterile water will yield 3 mL of
reconstituted solution. How many milliliters of the antibiotic should be
added to the 50 mL IVPB bag? Record your answer using one decimal
place. __ mL
1.5
1
,6. The nurse is caring for a non-ambulatory client with a reddened sacrum
that is unrelieved by repositioning. What nursing diagnosis should be
included on the client's plan of care?
Risk for pressure ulcer
Risk for impaired skin integrity
Impaired skin integrity, related to infrequent turning and repositioning
Impaired skin integrity, related to the effects of pressure and shearing force
7. A client has a pressure ulcer that is full thickness with necrosis into the
subcutaneous tissue down to the underlying fascia. The nurse should
document the assessment finding as which stage of pressure ulcer?
Stage I
Stage II
Stage III
Unstageable
A pressure ulcer with necrotic tissue is unstageable. The necrotic tissue must be
removed before the wound can be staged. A stage I pressure ulcer is defined as an
area of persistent redness with no break in skin integrity. A stage II pressure ulcer
is a partial-thickness wound with skin loss involving the epidermis, dermis, or both;
the ulcer is superficial and may present as an abrasion, blister, or shallow crater. A
stage III pressure ulcer involves full thickness tissue loss with visible subcutaneous
fat. Bone, tendon, and muscle are not exposed.
8. A client is being admitted for a total hip replacement. When is it
necessary for the nurse to ensure that a medication reconciliation is
completed? Select all that apply.
After reporting severe pain
On admission to the hospital
Upon entering the operating room
Before transfer to a rehabilitation facility
At time of scheduling for the surgical procedure
Medication reconciliation involves the creation of a list of all medications the client
is taking and comparing it to the health care provider's prescriptions on admission
or when there is a transfer to a different setting or service, or discharge. A change
in status does not require medication reconciliation. A medication reconciliation
should be completed long before entering the operating room. Total hip
replacement is elective surgery, and scheduling takes place before admission;
medication reconciliation takes place when the client is admitted.
9. A client is taking lithium sodium (Lithium). The nurse should notify the
health care provider for which of the following laboratory values?
White blood cell (WBC) count of 15,000 mm3
Negative protein in the urine
2
, Blood urea nitrogen (BUN) of 20 mg/dL
Prothrombin of 12.0 seconds
White cell counts can increase with this drug. The expected range of the WBC
count is 5000 to 10,000 mm3 for a healthy adult. Urinalysis, BUN, and prothrombin
are not necessary and these are normal values.
10. Often when a family member is dying, the client and the family are
at different stages of grieving. During which stage of a client's grieving is
the family likely to require more emotional nursing care than the client?
Anger
Denial
Depression
Acceptance
In the stage of acceptance, the client frequently detaches from the environment
and may become indifferent to family members. In addition, the family may take longer
to accept the inevitable death than does the client. Although the family may not
understand the anger, dealing with the resultant behavior may serve as a diversion.
Denial often is exhibited by the client and family members at the same time. During
depression, the family often is able to offer emotional support, which meets their needs.
11. The client asks the nurse to recommend foods that might be
included in a diet for diverticular disease. Which foods would be
appropriate to include in the teaching plan? Select all that apply.
Whole grains
Cooked fruit and vegetables
Nuts and seeds
Lean red meats
Milk and eggs
With diverticular disease the patient should avoid foods that may obstruct the
diverticuli. Therefore the fiber should be digestible, such as whole grains, and
cooked fruits and vegetables. Milk and eggs have no fiber content but are good
sources of protein. In clients with diverticular disease, nuts and seeds are
contraindicated as they may be retained and cause inflammation and infection,
which is known as diverticulitis. The client should also decrease intake of fats and
red meats.
12. A nurse is obtaining a health history from the newly admitted client
who has chronic pain in the knee. What should the nurse include in the
pain assessment? Select all that apply.
Pain history, including location, intensity, and quality of pain
3
