FUNDAMENTALS HESI PRACTICE

1. Older female client can't sleep at night. Nurse recommends SATA A. Take afternoon nap B. Ask HCP for prescription of mild sedative at bedtime C. Establish regular time for getting up and going to bed D. Drink whiskey, water and honey before bed E. Avoid drinking caffeine before bedtime Ans: C, E 2. The nurse has been alerted by the EMR when scanning the dispensed medication that the dosage is two times higher than the prescribed dose. The nurse should: A. Report mismatch of prescription and available dosages B. Withhold medication until exact dose is available C. Ask pharmacy if another dose can be dispensed D. Calculate dose on hand to match the prescribed dose Ans: D 3. A patient diagnosed with small bowel obstruction refuses surgery. The nurse should: A. Assess client needs for antiemetics and pain medications B. Prepare nasogastric tube compress C. Sent patient to CT abdominal scan D. Notify HCP that patient refuses surgery Ans: D 4. What is the most important factor for obesity referral? A. BMI 35 B. Client expressed desire to lose 50 pounds C. Body weight is 10% over ideal weight D. Daily calorie intake is 3,500 Ans: A 5. An elderly patient returns to the clinic for chronic pain management. He is prescribed MS Contin PO Q12H. He states that he only takes it when the pain is so severe that he can't sleep. A. Long time use of opioids may cause drug addiction B. Take medication Q12H as prescribed C. Teach alternative methods for pain management D. Continue taking MS Contin for severe pain. Ans: B 6. IM ventrogluteal landmark A. Upper outer quadrant of buttock B. Deltoid C. Knee and greater trochanter D. Greater trochanter and anterior superior iliac spine Ans: D 7. A client with a nasogastric tube is receiving low intermittent suction and is complaining of dry mouth. What should the nurse implement? A. Tell the client that the mucosa must stay dry to prevent aspiration B. Turn off suction so that the client can rinse his mouth with cold water C. Provide oral sponge toothettes so the client can clean and moisten his mouth D. Instill 50 mL of normal saline and clamp Ans: C 8. A client who is 12 days post op complains of thoracic incisional pain 2 hours after he received his pain medication. The HCP has been called. What should the nurse do next? A. Guided imagery and deep breathing B. Turn on a T.V. show and music for distraction C. Put a hot device on the area D. Provide a 20 minute back massage Ans: A 9. A post-op patient is grimacing when moving from bed to chair but denies pain. What should the nurse do next? A. Administer pain medication PRN B. Review his pain medications that are prescribed C. Monitor patient's nonverbal actions D. Ask what is making him grimace Ans: D 10. A client is on a mechanical soft diet and is constipated. He requests for prune juice. The nurse should: A. Restrict fluid B. Initiate bowel training protocol C. Advance to regular diet D. Offer to warm up the prune juice Ans: D 11. The nurse is assessing a client's ability to perform activities of daily living (ADL) safely. The client has steady gait and is able to ambulate from the door to the bed with full ROM. The nurse should: A. Teach the client to take shorter strides for better balance B. Record client's ability to perform ADL safely C. Initiate fall risk protocol D. Determine client's activity tolerance Ans: D 12. A patient is demonstrating diaphragmatic breathing by holding her abdomen while inhaling and removing her hands during exhalation. A. The demonstration was successful B. The hands do not need be on the abdomen, but the demonstration was still correct C. Keep light pressure on abdomen and cough after inspiration D. Expand abdomen during inspiration and let the abdomen sink during exhalation Ans: D 13. Highest priority? A. Impaired bed mobility B. Fluid volume deficit C. Bowel incontinence D. Caregiver role strain Ans: B 14. The computer system shuts down while the nurse was inputting client data. What should the nurse do next? A. Print EMR from backup server B. Wait for notification that the EMR is rebooted C. Identify information as late entry D. Notify IT Ans: D 15. The student nurse assesses an adult client's TM by pulling the ear up and back. The preceptor: A. Provides positive reinforcement to the student nurse for using correct technique B. Tells the student nurse that the ear should be pulled down Ans: A 16. How should the nurse instruct the mother of an adolescent with Diabetes Type 1 to inject insulin? [Picture of injection at deltoid] A. Correct her to the proper injection site B. Instruct mother how to insert needle with dart-like motion Ans: B 17. A client in pre-op reports "I feel funny all over...my belly feels weird" right before surgery. What is the nurse's best response? A. "Describe what your HCP told you regarding your surgery." B. "You say you feel funny everywhere. Is it located mostly in your stomach?" C. "Are you becoming frightened?" D. "Tell me more about the feelings in your belly." ... 18. Which related data should be obtained if a client is wheezing? A. Radiates to other parts of the body B. Heart sounds C. Body temperature D. Precipitating factors Ans: D 19. Picture of a nurse about to open an ampule. What should the nurse do next? A. Clean neck of ampule with alcohol B. Position gauze around neck of ampule C. Apply clean gloves before breaking the ampule open D. Snap neck away from hands Ans: B 20. UAP is not fitted for a respirator mask and requests to be re-assigned from a client with droplet precautions. The charge nurse should: A. Before changing assignments, check to see which nurses are fitted for the respirators B. Send UAD to get fitted for the respirator immediately so that she can return to take care of the patient C. Tell the UAP that she can wear a standard mask during vitals and use a respirator mask for other tasks D. Tell the UAP that a standard face mask is sufficient Ans: D 21. Patient complains that he hates how his boss orders him around and how he doesn't listen to his ideas. What is the nurse's best response? A. "I'm sure that it will get better with time." B. "It must be difficult for you to work in a place that makes you feel so bad." C. "How do you feel when your boss doesn't listen to you?" D. "You should change how you interact with your boss." Ans: C 22. A Native American client complains of abdominal cramping and nausea. What is the most important factor to assess? A. Family decision-making regarding health B. Recent use of home remedies and herbs C. Employment status Ans: B 23. A patient with a latex allergy needs a dressing change. The nurse notices redness on the skin around the draining wound. The nurse should: A. Obtain sample from draining wound B. Replace dressing with cotton gauze and silk tape C. Measure ankle to brachial index D. Administer antibiotics Ans: B 24. A nurse is educating a client on 24-hour urine test. The client states that the first void is in the urinal. A. Add the urine from the urinal to the collection container B. Start collecting with next void C. Start collecting the next day D. Check urine for sediments Ans: B 25. A Muslim female comes to the clinic for an initial assessment A. Obtain most of her history from her family members B. Determine what the client consider to be her ethnicity Ans: B 26. Which outcome is appropriate for the planning stage? A. The client will adhere to medication after discharge B. The client will successfully demonstrate dressing change within 2 days of hospitalization C. The nurse will assess the patient every 2 hours Ans: B 27. Which is the most appropriate method to teach young adults? A. Simulation activities B. Positive reinforcement C. Physical demonstrations D. Verbal analogies Ans: A 28. What to assess first for a client with cyanosis A. Temperature B. Heart rate C. Blood pressure D. Respiratory rate Ans: D 29. What should the nurse implement when inserting an indwelling catheter to an uncircumcised male. A. Clean meatus before retracting the foreskin B. Advance catheter before inflating balloon C. Sterile field should be even between nurse's hips D. Wipe the meatus back and forth Ans: B 30. A nurse notices a fire in the bathroom of an empty room and reports the location of the fire immediately. What should the nurse do next? A. Close the door to all the client's rooms in the hallway B. Evacuate clients in the rooms close to the fire C. Shut the door to the bathroom and the empty room D. Obtain fire extinguisher on the unit Ans: C 31. HCP tells the nurse that he will be prescribing a placebo to a client. The nurse should: A. Inform the nurse supervisor and refuse to administer placebo B. Administer the placebo to the client C. Inform the patient that he will be receiving a placebo D. Discuss ethical concerns with HCP Ans: D 32. Proper method of wound care A. Cleaning outwards to inward B. Cleaning inward to outward C. Cleaning back and forth D. Wiping sterile cotton swab twice Ans: B 33. A nurse walks into a client's room to see him coughing non-productively into his upper sleeve. The nurse should: A. Obtain face masks for all staff entering client's room B. Teach client how to cough into his hands C. Provide tissues for the client to cough into Ans: C