HESI RN FUNDAMENTALS EXAM
A 20-year-old female client with a noticeable body odor has refused to shower for
the last 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D.Teach the importance of personal hygiene during menstruation with the client. -
ANSWER: Teach the importance of personal hygiene during menstruation with the
client.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D.Purchase a newer model wheelchair - ANSWER: Change positions in the chair at
least every hour.
After a needle stick occurs while removing the cap from a sterile needle, which
action should the nurse implement?
A. Complete an incident report.
B. Select another sterile needle.
C.Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately. - ANSWER: Select another
sterile needle.
After receiving written and verbal instructions from a clinic nurse about a newly
prescribed medication, a client asks the nurse what to do if questions arise about the
medication after getting home. How should the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently asked
questions about medications.
B. Advise the client to obtain a current edition of a drug reference book from a local
bookstore or library.
C.Reassure the client that information about the medication is included in the
written instructions.
D. Encourage the client to call the clinic nurse or health care provider if any
questions arise. - ANSWER: Encourage the client to call the clinic nurse or health care
provider if any questions arise.
After the nurse tells an older client that an IV line needs to be inserted, the client
becomes very apprehensive, loudly verbalizing a dislike for all health care providers
and nurses. How should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
, C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure. - ANSWER:
Calmly reassure the client that the discomfort will be temporary.
Based on the nursing diagnosis of risk for infection, which intervention is best for the
nurse to implement when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C.Insert an indwelling urinary catheter
D. Instruct client in the use of adult diapers. - ANSWER: Maintain standard
precautions.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the
chainof infection?
A.Mode of transmission
B.Portal of entry
C.Reservoir
D.Portal of exit - ANSWER: Mode of transmission
A client becomes angry while waiting for a supervised break to smoke a cigarette
outsideand states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client. - ANSWER: Review the
schedule of outdoor breaks with the client.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should the
nurse dofirst?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ANSWER: Turn off the intermittent
suction device.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which
client instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ANSWER: Decrease intake
of fluids after the evening meal.
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first?
A 20-year-old female client with a noticeable body odor has refused to shower for
the last 3 days. She states, "I have been told that it is harmful to bathe during my
period." Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D.Teach the importance of personal hygiene during menstruation with the client. -
ANSWER: Teach the importance of personal hygiene during menstruation with the
client.
A 65-year-old client who attends an adult daycare program and is wheelchair-mobile
has redness in the sacral area. Which instruction is most important for the nurse to
provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D.Purchase a newer model wheelchair - ANSWER: Change positions in the chair at
least every hour.
After a needle stick occurs while removing the cap from a sterile needle, which
action should the nurse implement?
A. Complete an incident report.
B. Select another sterile needle.
C.Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately. - ANSWER: Select another
sterile needle.
After receiving written and verbal instructions from a clinic nurse about a newly
prescribed medication, a client asks the nurse what to do if questions arise about the
medication after getting home. How should the nurse respond?
A. Provide the client with a list of Internet sites that answer frequently asked
questions about medications.
B. Advise the client to obtain a current edition of a drug reference book from a local
bookstore or library.
C.Reassure the client that information about the medication is included in the
written instructions.
D. Encourage the client to call the clinic nurse or health care provider if any
questions arise. - ANSWER: Encourage the client to call the clinic nurse or health care
provider if any questions arise.
After the nurse tells an older client that an IV line needs to be inserted, the client
becomes very apprehensive, loudly verbalizing a dislike for all health care providers
and nurses. How should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
, C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure. - ANSWER:
Calmly reassure the client that the discomfort will be temporary.
Based on the nursing diagnosis of risk for infection, which intervention is best for the
nurse to implement when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
C.Insert an indwelling urinary catheter
D. Instruct client in the use of adult diapers. - ANSWER: Maintain standard
precautions.
By rolling contaminated gloves inside-out, the nurse is affecting which step in the
chainof infection?
A.Mode of transmission
B.Portal of entry
C.Reservoir
D.Portal of exit - ANSWER: Mode of transmission
A client becomes angry while waiting for a supervised break to smoke a cigarette
outsideand states, "I want to go outside now and smoke. It takes forever to get
anything done here!" Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client. - ANSWER: Review the
schedule of outdoor breaks with the client.
A client has a nasogastric tube connected to low intermittent suction. When
administering medications through the nasogastric tube, which action should the
nurse dofirst?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
D. Turn off the intermittent suction device. - ANSWER: Turn off the intermittent
suction device.
A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which
client instruction is important for the nurse to provide?
A. Decrease intake of fluids after the evening meal.
B. Drink a glass of cranberry juice every day.
C. Drink a glass of warm decaffeinated beverage at bedtime.
D. Consult the health care provider about a sleeping pill. - ANSWER: Decrease intake
of fluids after the evening meal.
A client in a long-term care facility reports to the nurse that he has not had a bowel
movement in 2 days. Which intervention should the nurse implement first?
