HESI Fundamentals V.2 CORRECT
SOLUTIONS
The nurse observes a newly admitted older adult female take short
steps and walk very slowly while pushing a walker in front of her.
What action should the nurse take in response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
A) Complete a full fall risk assessment of the client.
While suctioning a client's nasopharynx, the nurse observes that the
client's oxygen saturation remains at 94%, which is the same reading
obtained prior to starting the procedure. What action should the
nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth.
C) Complete the intermittent suction of the nasopharynx.
An older woman with end stage heart disease is hospitalized for
severe heart failure. She is alert, oriented, and requests that no
heroic measures are implemented if her breathing stops. What action
should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care.
A) Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a
prescription for biotic eye drops, pilocarpine HCl (Pilocarpine).
What instruction should the nurse plan to include in this client's
teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
,C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops."
A) "Do not allow the dropper bottle to touch the eye."
When assessing a client who starts to wheeze related data should
obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
D) Precipitating factors.
The home health nurse is reviewing the personal care of an elderly
client who lives alone. Which client assessment findings indicate the
need to assign unlicensed assistive personnel (UAP) to provide
routine foot care and file the client's toenails? Select all that
apply.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
A client is discharged to a long-term care facility with an
indwelling urinary catheter. Which nursing action should be included
in the plan to reduce the client's risk for infection related to the
catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
B) Encourage increased intake of oral fluids.
To assess the quality of an adult client's pain, what approach should
the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
C) Ask the client to describe the pain.
,A client who has been diagnosed with terminal cancer tells the nurse,
"The doctor told me I have cancer and do not have long to live."
Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
D) "Yes, your condition is serious."
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside.
C) Position the client supine for a few minutes.
The nurse is providing passive range of motion (ROM) exercises to the
hip and knee for a client who is unconscious. After supporting the
client's knee with one hand, what action should the nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel.
D) Cradle the client's heel.
The nurse is preparing to irrigate a client's indwelling urinary
catheter using an open technique. What action should the nurse take
after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution.
B) Draw up the irrigating solution into the syringe.
Which client care requires the nurse to wear barrier gloves as
required by the protocol for Standard Precautions?
A) Removing the empty food tray from a client with a urinary catheter.
B) Washing and combing the hair of a client with a fractured leg in
traction.
C) Administering oral medications to a cooperative client with a
, wound infection.
D) Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease.
D) Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease.
What action should the nurse implement to prevent the formation of a
sacral ulcer for a client who is immobile?
A) Maintain in a lateral position using protective wrist and vest
devices.
B) Position prone with a small pillow below the diaphragm.
C) Raise the head and knee gatch when lying in a supine position.
D) Transfer into a wheelchair close to the nurse's station for
observation.
B) Position prone with a small pillow below the diaphragm.
At 0100 on a male client's second postoperative night, the client
states he is unstable to sleep and plans to read until feeling sleepy.
What action should the nurse implement?
A) Leave the room and close the door to the client's room.
B) Assess the appearance of the client's surgical dressing.
C) Bring the client a prescribed PRN sedative-hypnotic.
D) Discuss symptoms of sleep deprivation with the client.
C) Bring the client a prescribed PRN sedative-hypnotic.
The nursing staff in the cardiovascular intensive care unit are
creating a continuous quality improvement project on social media
that addresses coronary artery disease (CAD). Which action should the
nurse implement to protect client privacy?
A) Remove identifying information of the clients who participated.
B) Recall that authored content may be legally discoverable.
C) Share material from credible, peer reviewed sources only.
D) Respect all copyright laws when adding website content.
A) Remove identifying information of the clients who participated.
A male client with unstable angina needs a cardiac catheterization,
so the healthcare provider explains the risks and benefits of the
procedure, and then leaves to set up for the procedure. When the
nurse presents the consent form for signature, the client hesitates
and asks how the wires will keep his heart going. Which action should
the nurse take?
A) Answer the client's specific questions with a short understandable
explanation.
SOLUTIONS
The nurse observes a newly admitted older adult female take short
steps and walk very slowly while pushing a walker in front of her.
What action should the nurse take in response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
A) Complete a full fall risk assessment of the client.
While suctioning a client's nasopharynx, the nurse observes that the
client's oxygen saturation remains at 94%, which is the same reading
obtained prior to starting the procedure. What action should the
nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
D) Apply an oxygen mask over the client's nose and mouth.
C) Complete the intermittent suction of the nasopharynx.
An older woman with end stage heart disease is hospitalized for
severe heart failure. She is alert, oriented, and requests that no
heroic measures are implemented if her breathing stops. What action
should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a "do not resuscitate" (DNR) prescription.
C) Set up a family conference to discuss the client's.
D) Consult the palliative care team about client's care.
A) Discuss with the client her meaning of heroic measures.
A client diagnosed with primary open-angle glaucoma received a
prescription for biotic eye drops, pilocarpine HCl (Pilocarpine).
What instruction should the nurse plan to include in this client's
teaching?
A) "Do not allow the dropper bottle to touch the eye."
B) "Administer the medication directly on the cornea."
,C) "Squeeze your eye closed after administering the drops."
D) "Wash your hands after each administration of eye drops."
A) "Do not allow the dropper bottle to touch the eye."
When assessing a client who starts to wheeze related data should
obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
D) Precipitating factors.
The home health nurse is reviewing the personal care of an elderly
client who lives alone. Which client assessment findings indicate the
need to assign unlicensed assistive personnel (UAP) to provide
routine foot care and file the client's toenails? Select all that
apply.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
A) Syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
A client is discharged to a long-term care facility with an
indwelling urinary catheter. Which nursing action should be included
in the plan to reduce the client's risk for infection related to the
catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
B) Encourage increased intake of oral fluids.
To assess the quality of an adult client's pain, what approach should
the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
C) Ask the client to describe the pain.
,A client who has been diagnosed with terminal cancer tells the nurse,
"The doctor told me I have cancer and do not have long to live."
Which response is best for the nurse to provide?
A) "That's correct, you do not have long to live."
B) "Would you like me to call your minister?"
C) "Don't give up, you still have chemotherapy to try."
D) "Yes, your condition is serious."
D) "Yes, your condition is serious."
When performing blood pressure measurement to assess for orthostatic
hypotension, which action should the nurse implement first?
A) Apply the blood pressure cuff securely.
B) Record the client's pulse rate and rhythm.
C) Position the client supine for a few minutes.
D) Assist the client to stand at bedside.
C) Position the client supine for a few minutes.
The nurse is providing passive range of motion (ROM) exercises to the
hip and knee for a client who is unconscious. After supporting the
client's knee with one hand, what action should the nurse take next?
A) Raise the bed to a comfortable working level.
B) Bend the client's knee.
C) Move the knee toward the chest as far as it will go.
D) Cradle the client's heel.
D) Cradle the client's heel.
The nurse is preparing to irrigate a client's indwelling urinary
catheter using an open technique. What action should the nurse take
after applying gloves?
A) Empty the client's urinary drainage bag.
B) Draw up the irrigating solution into the syringe.
C) Secure the client's catheter to the drainage tubing.
D) Use aseptic technique to instill the irrigating solution.
B) Draw up the irrigating solution into the syringe.
Which client care requires the nurse to wear barrier gloves as
required by the protocol for Standard Precautions?
A) Removing the empty food tray from a client with a urinary catheter.
B) Washing and combing the hair of a client with a fractured leg in
traction.
C) Administering oral medications to a cooperative client with a
, wound infection.
D) Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease.
D) Emptying the urinary catheter drainage bag for a client with
Alzheimer's disease.
What action should the nurse implement to prevent the formation of a
sacral ulcer for a client who is immobile?
A) Maintain in a lateral position using protective wrist and vest
devices.
B) Position prone with a small pillow below the diaphragm.
C) Raise the head and knee gatch when lying in a supine position.
D) Transfer into a wheelchair close to the nurse's station for
observation.
B) Position prone with a small pillow below the diaphragm.
At 0100 on a male client's second postoperative night, the client
states he is unstable to sleep and plans to read until feeling sleepy.
What action should the nurse implement?
A) Leave the room and close the door to the client's room.
B) Assess the appearance of the client's surgical dressing.
C) Bring the client a prescribed PRN sedative-hypnotic.
D) Discuss symptoms of sleep deprivation with the client.
C) Bring the client a prescribed PRN sedative-hypnotic.
The nursing staff in the cardiovascular intensive care unit are
creating a continuous quality improvement project on social media
that addresses coronary artery disease (CAD). Which action should the
nurse implement to protect client privacy?
A) Remove identifying information of the clients who participated.
B) Recall that authored content may be legally discoverable.
C) Share material from credible, peer reviewed sources only.
D) Respect all copyright laws when adding website content.
A) Remove identifying information of the clients who participated.
A male client with unstable angina needs a cardiac catheterization,
so the healthcare provider explains the risks and benefits of the
procedure, and then leaves to set up for the procedure. When the
nurse presents the consent form for signature, the client hesitates
and asks how the wires will keep his heart going. Which action should
the nurse take?
A) Answer the client's specific questions with a short understandable
explanation.
