NURSING HESI FUNDAMENTALS EXAM 2024 COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS)

NURSING HESI FUNDAMENTALS EXAM 2024 COMPLETE QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) A 35-year-old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home to die. What intervention should the nurse initiate? A) Review the client's medical record for an advance directive. B) Determine if a do-not-resuscitate prescription has been obtained. C) Document that the client is being discharged against medical advice. D) Evaluate the client's mental status for competence to refuse treatment. - ANSWER-Answer: D Rationale Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. .A 4-year-old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, "Will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? A) "It may hurt a little because of the incision made in your throat." B) "It won't hurt because you're such a big boy." C) "It won't hurt because we put you to sleep." D) "It may hurt but we'll give you medicine to help you feel better." - ANSWER-Answer: D Rationale Answering questions simply and directly provides comfort for the preschool-age child and builds confidence in the health care team (D). (A) uses language (i.e. 'incision') that could create anxiety for the child. Four-year-olds are in the Initiative vs. Guilt stage (Erikson's psychosocial development), and (B) contributes to guilt when the child hurts. (C) is not helpful because the child may associate "being put to sleep" with the postoperative throat pain and then become fearful of going to sleep. .A 73-year-old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A) Amount of liquid protein supplements consumed daily. B) Foods and liquids consumed during the past 24 hours. C) Usual weekly intake of milk products and red meats. D) Grains and legume combinations used by the client. - ANSWER-Answer: B Rationale A client's dietary habits should be determined first by the client's dietary recall (B) before suggesting protein sources or supplements (A and C) as options in the client's diet. Although grains and legumes (D) contain incomplete proteins that reduces the essential amino acid pools inside the cells, the client's cultural preferences should be elicited after confirming the client's dietary history. .A 75-year-old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR directive. What is the priority nursing intervention? A) Review the client's most recent laboratory reports. B) Refer the client and family members for hospice care. C) Notify the hospital ethics committee of the client situation. D) Determine who is legally empowered to make decisions. - ANSWER-Answer: D Rationale When death is impending, it is essential for the nurse to determine who is legally empowered to make decisions regarding the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to death, but is of less immediacy than determining whether actions should be taken to save a client's life. If the nurse remains unable to determine who is empowered to make decisions in this situation, the nurse may choose to contact the ethics committee (C) for a resolution. .A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A) Help the client to accept the final stage of life. B) Assist and support the client in establishing short-term goals. C) Encourage the client to make future plans, even if they are unrealistic. D) Instruct the client's family to focus on positive aspects of the client's life. - ANSWER-Answer: B Rationale Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B). .A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? A) Ensure cultural customs are observed. B) Increase oxygen flow to 4L/minute. C) Auscultate bilateral lung fields. D) Inform the family that death is imminent. - ANSWER-Answer: D Rationale An audible gurgling sound produced by a dying client is characteristic of ineffective clearance of secretions from the lungs or upper airways, causing a "rattling" sound as air moves through the accumulated fluid. The nursing priority in this situation is to convey to the family that the client's death is imminent (D). Although culturally sensitive care should be observed throughout the client's plan of care (A), this is not the priority at this time. Administration of oxygen may be expected care, but a flow rate greater than 2 L/minute (B) is not palliative care. (C) may provide additional information, but is not necessary as death approaches. .A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A) Take measures to promote as much comfort as possible. B) Report any signs of drug addiction to the nurse immediately. C) Wait until the client's pain is gone before assisting with personal care. D) This client's pain will be difficult to manage, since the cause is unknown. - ANSWER-Answer: A Rationale Intractable pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during all activities. A client with intractable pain may develop drug tolerance and dependence, but (B) is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause. .A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A) Hydrogel. B) Exudate absorber. C) Wet to moist dressing. D) Transparent adhesive film. - ANSWER-Answer: C Rationale To provide moisture and loosen the necrotic tissue, the eschar should be covered first with wet to moist dressings (C), which are discontinued, and then a hydrogel alginate can be placed in the prepared wound bed to prevent further damage of granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic tissue of slough and rehydrates the wound bed, it does not address wicking the purulent drainage from the wound. Exudate absorbers (B) provide a moist wound surface, absorb exudate, and support debridement, but do not prepare the wound bed for proper healing. Transparent dressings (D) are used to protect against contamination and friction while maintaining a clean moist surface. .A client is demonstrating a positive Chvostek's sign. What action should the nurse take? A) Observe the client's pupil size and response to light. B) Ask the client about numbness or tingling in the hands. C) Assess the client's serum potassium level. D) Restrict dietary intake of calcium-rich foods. - ANSWER-Answer: B Rationale A positive Chvostek's sign is an indication of hypocalcemia, so the client should be assessed for the subjective symptoms of hypocalcemia, such as numbness or tingling of the hands (B) or feet. (A and C) are unrelated assessment data. (D) is contraindicated because the client is hypocalcemic and needs additional dietary calcium. .A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A) Solicit information on hospitalization from the insurance company. B) Look up previous medical records from archived hospital documents. C) Ask the client to discuss previous hospitalizations in the last 5 years. D) Elicit specific facts about past hospitalizations with direct questions. - ANSWER-Answer: D Rationale Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts about past health problems. .A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A) Encourage the client to take several slow, deep breaths while ambulating. B) Help the client to remain standing by the bedside until the dizziness is relieved. C) Instruct the client to remain on bedrest until the healthcare provider is contacted. D) Advise the client to sit on the side of the bed for a few minutes before standing again. - ANSWER-Answer: D Rationale The nurse should implement (D), because orthostatic hypotension is a common result of immobilization, causing the client to feel dizzy when first getting out of bed following a period of bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will increase the potential for complications associated with prolonged immobility. .A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? A) Continue gabapentin. B) Discontinue ibuprofen. C) Add aspirin to the protocol. D) Add oral methadone to the protocol. - ANSWER-Answer: A Rationale Based on the WHO pain relief ladder, adjunct medications, such as gabapentin (Neurontin), an antiseizure medication, may be used at any step for anxiety and pain management, so (A) should be implemented. Nonopiod analgesics, such as ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics (D), and to maintain freedom from pain, drugs should be given "around the clock" rather than by the client's PRN requests. .A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the client's protein status for the longest length of time? A) Transferrin. B) Prealbumin. C) Serum albumin. D) Urine urea nitrogen. - ANSWER-Answer: C Rationale