HESI NCLEX-RN Fundamentals EXAM
1. In completing a client's preoperative routine, the nurse finds that the
operative permit is not signed. The client begins to ask more questions about
the surgical procedure. What action should the nurse take next?:
Answer:
Inform the surgeon the operative permit is not signed and the client has questions
about the surgery.
Rationale:
The surgeon should be informed immediately that the permit is not signed
2. A hospitalized client has had difficulty falling asleep for two nights and is
becoming irritable and restless. What action by the nurse is best?:
Answer:
Determine the client's usual bedtime routine and include these rituals in the plan of
care as safety allows.
Rationale:
Including habitual rituals that do not interfere with the client's care or safety may
allow the client to go to sleep faster and increase the quality of care
3. After the nurse tells an older male client that an IV line needs to be
inserted, he becomes very apprehensive, loudly verbalizing his dislike for
all healthcare providers and nurses. How should the nurse respond?:
Answer:
Calmly reassure the client that the discomfort will be temporary.
Rationale:
The nurse should respond with a calm demeanor (C) to help reduce the client's
apprehension. After responding calmly to the client's apprehension
4. 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." What action should the nurse take first?:
Answer:
Discuss the importance of personal hygiene during menstruation with the client.
Rationale:
Since a shower is most beneficial for the client in terms of hygiene and mobility,
the client should receive teaching first (D), respecting any personal beliefs, such
as cultural or spiritual values.
5. When the healthcare provider diagnoses metastatic cancer and recommends
,a gastrostomy for an older female client in stable condition, the son
tells the nurse that his mother must not be told the reason for the surgery,
because she "can't handle" the cancer diagnosis. What legal principle is
the court most likely to uphold regarding this client's right to informed
consent?:
Answer:
If informed consent is withheld from a client, healthcare providers could be found
guilty of negligence.
Rationale:
Healthcare providers may be found guilty of negligence (D), specifically, assault
and battery, if they carry out a treatment without the client's consent. The client's
condition is stable, so (A) is not a valid rationale. Advanced age does not
automatically authorize the son to make all decisions for his mother, and there is
no evidence that the client is mentally incompetent
6. 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?:
Answer:
Assess the client's medical record to determine the client's normal bowel pattern.
Rationale:
This client may not routinely have a daily bowel movement, so the nurse should
first assess this client's normal bowel habits before attempting any intervention
7. When emptying 350 ml of pale yellow urine from a client's urinal, the
nurse notes that this is the first time the client has voided in 4 hours. What
action should the nurse take next?:
Answer:
Record the amount on the client's fluid output record.
Rationale:
The amount and appearance of the client's urine output is within normal limits, so
the nurse should record the output (A), but no additional action is needed
8. Which client is most likely to be at risk for spiritual distress?:
Answer:
A Roman Catholic woman considering an abortion
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing
this decision may place the client at risk for spiritual distress
, 9. The nurse teaches the use of a gait belt to a male caregiver whose
spouse has right-sided weakness and needs assistance with ambulation.
The caregiver performs a return demonstration of the skill. Which observation
indicates that the caregiver has learned how to perform this procedure
correctly?:
Answer:
Standing on his spouse's weak side, the caregiver provides security by holding the
gait belt from the back.
Rationale:
The spouse is most likely to lean toward the weak side and needs extra support
on that side and from the back (B) to prevent falling.
10. A client has a nursing diagnosis of, "Altered sleep patterns related to
nocturia." Which client instruction is important for the nurse to provide?: -
Answer:
Decrease intake of fluids after the evening meal.
Rationale:
Nocturia is urination during the night. (A) is helpful to decrease the production of
urine, thus decreasing the need to void at night.
11. The nurse is assessing several clients prior to surgery. Which factor
in aclient's history poses the greatest threat for complications to occur
during surgery?:
Answer:
Taking anticoagulants for the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose
a threat for developing surgical complications. The healthcare provider should be
informed that the client is taking such drugs.
12. Urinary catheterization is prescribed for a postoperative female client
whohas been unable to void for 8 hours. The nurse inserts the catheter, but
no urine is seen in the tubing. What action will the nurse take next?:
Answer:
Leave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving
the first catheter in place will help locate the meatus when attempting the second
catheterization
1. In completing a client's preoperative routine, the nurse finds that the
operative permit is not signed. The client begins to ask more questions about
the surgical procedure. What action should the nurse take next?:
Answer:
Inform the surgeon the operative permit is not signed and the client has questions
about the surgery.
Rationale:
The surgeon should be informed immediately that the permit is not signed
2. A hospitalized client has had difficulty falling asleep for two nights and is
becoming irritable and restless. What action by the nurse is best?:
Answer:
Determine the client's usual bedtime routine and include these rituals in the plan of
care as safety allows.
Rationale:
Including habitual rituals that do not interfere with the client's care or safety may
allow the client to go to sleep faster and increase the quality of care
3. After the nurse tells an older male client that an IV line needs to be
inserted, he becomes very apprehensive, loudly verbalizing his dislike for
all healthcare providers and nurses. How should the nurse respond?:
Answer:
Calmly reassure the client that the discomfort will be temporary.
Rationale:
The nurse should respond with a calm demeanor (C) to help reduce the client's
apprehension. After responding calmly to the client's apprehension
4. 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." What action should the nurse take first?:
Answer:
Discuss the importance of personal hygiene during menstruation with the client.
Rationale:
Since a shower is most beneficial for the client in terms of hygiene and mobility,
the client should receive teaching first (D), respecting any personal beliefs, such
as cultural or spiritual values.
5. When the healthcare provider diagnoses metastatic cancer and recommends
,a gastrostomy for an older female client in stable condition, the son
tells the nurse that his mother must not be told the reason for the surgery,
because she "can't handle" the cancer diagnosis. What legal principle is
the court most likely to uphold regarding this client's right to informed
consent?:
Answer:
If informed consent is withheld from a client, healthcare providers could be found
guilty of negligence.
Rationale:
Healthcare providers may be found guilty of negligence (D), specifically, assault
and battery, if they carry out a treatment without the client's consent. The client's
condition is stable, so (A) is not a valid rationale. Advanced age does not
automatically authorize the son to make all decisions for his mother, and there is
no evidence that the client is mentally incompetent
6. 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?:
Answer:
Assess the client's medical record to determine the client's normal bowel pattern.
Rationale:
This client may not routinely have a daily bowel movement, so the nurse should
first assess this client's normal bowel habits before attempting any intervention
7. When emptying 350 ml of pale yellow urine from a client's urinal, the
nurse notes that this is the first time the client has voided in 4 hours. What
action should the nurse take next?:
Answer:
Record the amount on the client's fluid output record.
Rationale:
The amount and appearance of the client's urine output is within normal limits, so
the nurse should record the output (A), but no additional action is needed
8. Which client is most likely to be at risk for spiritual distress?:
Answer:
A Roman Catholic woman considering an abortion
Rationale:
In the Roman Catholic religion, any type of abortion is prohibited (A), so facing
this decision may place the client at risk for spiritual distress
, 9. The nurse teaches the use of a gait belt to a male caregiver whose
spouse has right-sided weakness and needs assistance with ambulation.
The caregiver performs a return demonstration of the skill. Which observation
indicates that the caregiver has learned how to perform this procedure
correctly?:
Answer:
Standing on his spouse's weak side, the caregiver provides security by holding the
gait belt from the back.
Rationale:
The spouse is most likely to lean toward the weak side and needs extra support
on that side and from the back (B) to prevent falling.
10. A client has a nursing diagnosis of, "Altered sleep patterns related to
nocturia." Which client instruction is important for the nurse to provide?: -
Answer:
Decrease intake of fluids after the evening meal.
Rationale:
Nocturia is urination during the night. (A) is helpful to decrease the production of
urine, thus decreasing the need to void at night.
11. The nurse is assessing several clients prior to surgery. Which factor
in aclient's history poses the greatest threat for complications to occur
during surgery?:
Answer:
Taking anticoagulants for the past year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose
a threat for developing surgical complications. The healthcare provider should be
informed that the client is taking such drugs.
12. Urinary catheterization is prescribed for a postoperative female client
whohas been unable to void for 8 hours. The nurse inserts the catheter, but
no urine is seen in the tubing. What action will the nurse take next?:
Answer:
Leave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving
the first catheter in place will help locate the meatus when attempting the second
catheterization
