HESI Fundamentals V1 Questions and Answers

HESI Fundamentals V1 Questions and Answers 1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse. Acrylic nails are known to carry loads of bacteria and increase the risk of healthcare-associated infections. Therefore, by banning the wearing of acrylic nails, you would expect the prevalence of healthcare-associated infections to decrease. Acrylic nails have nothing to do with staff induced injuries, needle-stick injuries, or patient satisfaction scores. 2. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. This is a method used to determine proper placement of NG tubing, but not the most accurate. B) Hearing air pass in the stomach after injecting air into the tubing. This is a method used to determine proper placement of NG tubing, but not the most accurate. C) Examining a chest x-ray obtained after the tubing was inserted. After placing an NG-tube, the placement of the tube is confirmed via x-ray since it is the most accurate way to ensure the tube has not been placed in the lungs, which would pose an aspiration risk. D) Checking the remaining length of tubing to ensure that the correct length was inserted. This is not an indicator of proper placement. You could very well be in a lung. 3. The father of an 11-year-old client reports to the nurse that the client has been “wetting the bed” since the passing of his mother and is concerned. Which action is most important for the nurse to enact? A. Reassure the father that it is normal for a pre-teen to wet the bed during puberty B. Inform the father that nocturnal emissions are abnormal and his son is developmentally Downloaded by denis munene () lOMoARcPSD| delayed C. Inform the father that it is most important to let the son know that nocturnal emissions are normal after trauma D. Refer the father and the client to a psychologist It is common for adolescents to regress in their biological progression after experiencing a severe trauma, like losing a parent, sibling, or friend. While uncomfortable for the adolescent and parent, it is nothing to be concerned for. Often times, as the patient grieves or comes to terms with the trauma, the nocturnal emissions will cease. 4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift? Downloaded by denis munene () lOMoARcPSD| A. Assess the client for confusion and reteach the procedure B. Check the urine for color and texture C. Empty the urinal contents into the 24-hour collection container D. Discard the contents of the urinal An “older adult male” in the question may imply that the patient may have an altered mental status or be demented. While suggesting, it is not directly stated, therefore (A) is inappropriate. (B) is incorrect because the lab will be assessing the collection specimen after the test is complete. (C) is correct because the nurse should first discard the first specimen, then begin to collect and record the time the first urine specimen was collected. It is important to have strict documentation for output, and to collect every urine specimen within that 24 hour period, otherwise the test must be restarted. (D) defeats the purpose of the 24-hour urine collection test. 5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to most beneficial? A. Ask her how she would like to participate in the client’s care. B. Provide the wife with information about hospice C. Encourage the wife to visit after painful treatments are completed D. Refer her to support group for family members of those dying of cancer While the client’s wife may be grieving and need support, the priority for the client and client’s wife is to make sure the wife feels comfortable participating in the client’s care, if at all. Most people have an easier time coming to terms with the death of a loved one when they are involved in their care. (D) is a nice gesture, but will be more appropriate at a later time. 6. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recomm