FUNDAMENTALS HESI EXAM QUIZZES WITH ACTUAL
ANSWERS.
The,nurse,is,preparing,a,male,client,who,has,an,indwelling,catheter,and,an,IV,infusion,to,ambulate
,from,the,bed,to,a,chair,for,the,first,time,following,abdominal,surgery.,What,action(s),should,the,nurse,
implement,prior,to,assisting,the,client,to,the,chair?,(Select,all,that,apply.)
A),Pre-medicate,the,client,with,an,analgesic
B),Inform,the,client,of,the,plan,for,moving,to,the,chair
C),Obtain,and,place,a,portable,commode,by,the,bed.
,D),Ask,the,client,to,push,the,IV,pole,to,the,chair.
,E),Clamp,the,indwelling,catheter.
,F),Assess,the,client's,blood,pressure.,,,ANS,-,A,B,D,F
Pre-
medicating,the,client,with,an,analgesic,(A),reduces,the,client's,pain,during,mobilization,and,maximizes,
compliance.,To,ensure,the,client's,cooperation,and,promote,independence,,the,nurse,should,inform,th
e,client,about,the,plan,for,moving,to,the,chair,(B),and,encourage,the,client,to,participate,by,pushing,th
e,IV,pole,when,walking,to,the,chair,(D).,The,nurse,should,assess,the,client's,blood,pressure,(F),prior,to,
mobilization,,which,can,cause,orthostatic,hypotension.,(C,and,E),are,not,indicated.
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,,,ANS,-,C
To,provide,moisture,and,loosen,the,necrotic,tissue,,the,eschar,should,be,covered,first,with,wet,to,mois
t,dressings,(C),,which,are,discontinued,and,then,a,hydrogel,alginate,can,be,placed,in,the,prepared,wou
nd,bed,to,prevent,further,damage,of,granulating,any,surrounding,tissue.,Although,a,hydrogel,(A),liquefi
es,necrotic,tissue,of,slough,and,rehydrates,the,wound,bed,,it,does,not,address,wicking,the,purulent,dra
,inage,from,the,wound.,Exudate,absorbers,(B),provide,a,moist,wound,surface,,absorb,exudate,,and,sup
port,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.
The,nurse,is,preparing,to,irrigate,a,client's,indwelling,urinary,catheter,using,an,open,technique.,What,a
ction,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.,,,ANS,-,B
To,irrigate,an,indwelling,urinary,catheter,,the,nurse,should,first,apply,gloves,,then,draw,up,the,irrigatin
g,solution,into,the,syringe,(B).,The,syringe,is,then,attached,to,the,catheter,and,the,fluid,instilled,,using,
aseptic,technique,(D).,Once,the,irrigating,solution,is,instilled,,the,client's,catheter,should,be,secured,to,
the,drainage,tubing,(C).,The,urinary,drainage,bag,can,be,emptied,(A),whenever,intake,and,output,meas
urement,is,indicated,,and,the,instilled,irrigating,fluid,can,be,subtracted,from,the,output,at,that,time.
While,caring,for,a,child,and,mother,from,Cambodia,,what,action,should,the,nurse,implement,to,accom
modate,the,clients',cultural,needs?
A),Speak,initially,with,the,oldest,family,member,to,show,respect.
B),Realize,that,Southeast,Asians,may,not,take,Western,medications.
C),Ask,the,husband,to,step,out,during,the,mother's,pelvic,examination.
D),Tell,the,family,that,planning,health,care,is,provided,in,private,with,the,client.,,,ANS,-,A
Members,of,the,Asian,culture,have,high,respect,for,others,,especially,those,in,positions,of,authority.,Ex
tended,family,members,need,to,be,included,in,the,nursing,care,plan,(A).,Southeast,Asians,do,not,neces
sarily,refuse,Western,medications,(B).,Asians,also,believe,that,touching,strangers,is,not,acceptable,,par
ticularly,health,professionals,whom,they,have,not,previously,known,,so,the,husband,should,be,allowed
,to,remain,with,his,wife,during,the,pelvic,exam,(C).,Provided,that,the,presence,of,other,family,member
s,is,not,harmful,to,the,client's,well-being,,(D),is,not,correct.
,The,nurse,removes,the,dressing,on,a,client's,heel,that,is,covering,a,pressure,sore,one-
inch,in,diameter,and,finds,that,there,is,straw-
colored,drainage,seeping,from,the,wound.,What,description,of,this,finding,should,the,nurse,include,in,t
he,client's,record?
A),Stage,1,pressure,sore,draining,sero-sanguineous,drainage.
B),Pressure,sore,at,bony,prominence,with,exudate,noted.
C),One-inch,pressure,sore,draining,serous,fluid.
D),Pressure,sore,on,heel,with,a,small,amount,of,purulent,drainage.,,,ANS,-,C
Serous,drainage,is,clear,watery,plasma,,so,(C),provides,accurate,documentation,based,on,the,informati
on,provided.,Information,to,stage,this,pressure,score,(A),is,not,provided,,and,sero-
sanguineous,drainage,is,pale,and,watery,with,a,combination,of,plasma,and,red,cells,,and,may,be,blood
-
streaked.,Exudate,(B),is,fluid,such,as,pus,and,serum.,Purulent,drainage,(D),is,thick,,yellow,,green,,or,br
own,indicating,the,presence,of,dead,or,living,organisms,and,white,blood,cells.
The,charge,nurse,assigns,a,nursing,procedure,to,a,new,staff,nurse,who,has,not,previously,performed,th
e,procedure.,What,action,is,most,important,for,the,new,staff,nurse,to,take?
A),Review,the,steps,in,the,procedure,manual.
B),Ask,another,nurse,to,assist,while,implementing,the,procedure.
C),Follow,the,agency's,policy,and,procedure.
D),Refuse,to,perform,the,task,that,is,beyond,the,nurse's,experience.,,,ANS,-,D
According,to,states',nurse,practice,acts,,it,is,the,responsibility,of,the,nurse,to,function,within,the,scope,
of,competency,(D),,and,in,this,case,safe,nursing,practice,constitutes,refusal,to,perform,the,procedure,b
ecause,of,a,lack,of,experience.,Although,state,mandates,,agency,policies,,and,continued,education,and,
experience,identify,tasks,that,are,within,the,scope,of,nursing,practice,,nurses,should,first,refuse,to,perf
orm,tasks,that,are,beyond,their,proficiency,,and,then,pursue,opportunities,to,enhance,their,competenc
y,(A,,B,,and,C).
A,male,client,with,venous,incompetence,stands,up,and,his,blood,pressure,subsequently,drops.,Which,fi
nding,should,the,nurse,identify,as,a,compensatory,response?
, ,
A),Bradycardia.
B),Increase,in,pulse,rate.
C),Peripheral,vasodilation.
D),Increase,in,cardiac,output.,,,ANS,-,B
When,postural,hypotension,occurs,,the,body,attempts,to,restore,arterial,pressure,by,stimulating,the,ba
ro-
receptors,to,increase,the,heart,rate,(B),,not,decrease,it,(A).,Peripheral,vasoconstriction,,not,dilation,(C),
,of,the,veins,and,arterioles,occurs,with,venous,incompetence,through,the,baro-
receptor,reflex.,A,decrease,in,cardiac,output,,not,an,increase,(D),,occurs,when,orthostatic,hypotension,
occurs.
A,client,with,Raynaud's,disease,asks,the,nurse,about,using,biofeedback,for,self-
management,of,symptoms.,What,response,is,best,for,the,nurse,to,provide?
A),The,responses,to,biofeedback,have,not,been,well,established,and,may,be,a,waste,of,time,and,mone
y.
B),Biofeedback,requires,extensive,training,to,retrain,voluntary,muscles,,not,involuntary,responses.
C),Although,biofeedback,is,easily,learned,,it,is,most,often,used,to,manage,exacerbation,of,symptoms.
D),Biofeedback,allows,the,client,to,control,involuntary,responses,to,promote,peripheral,vasodilation.,,,
ANS,-,D
Biofeedback,involves,the,use,of,various,monitoring,devices,that,help,people,become,more,aware,and,a
ble,to,control,their,own,physiologic,responses,,such,as,heart,rate,,body,temperature,,muscle,tension,,a
nd,brain,waves.,(D),is,an,accurate,statement,concerning,its,use,for,clients,with,Raynaud's,disease.,(A,,B
,,and,C),do,not,provide,correct,information,about,biofeedback.
A,female,client,who,has,breast,cancer,with,metastasis,to,the,liver,and,spine,is,admitted,with,constant,,
severe,pain,despite,around-the-
clock,use,of,oxycodone,(Percodan),and,amitriptyline,(Elavil),for,pain,control,at,home.,During,the,admis
sion,assessment,,which,information,is,most,important,for,the,nurse,to,obtain?
,
A),Sensory,pattern,,area,,intensity,,and,nature,of,the,pain.
ANSWERS.
The,nurse,is,preparing,a,male,client,who,has,an,indwelling,catheter,and,an,IV,infusion,to,ambulate
,from,the,bed,to,a,chair,for,the,first,time,following,abdominal,surgery.,What,action(s),should,the,nurse,
implement,prior,to,assisting,the,client,to,the,chair?,(Select,all,that,apply.)
A),Pre-medicate,the,client,with,an,analgesic
B),Inform,the,client,of,the,plan,for,moving,to,the,chair
C),Obtain,and,place,a,portable,commode,by,the,bed.
,D),Ask,the,client,to,push,the,IV,pole,to,the,chair.
,E),Clamp,the,indwelling,catheter.
,F),Assess,the,client's,blood,pressure.,,,ANS,-,A,B,D,F
Pre-
medicating,the,client,with,an,analgesic,(A),reduces,the,client's,pain,during,mobilization,and,maximizes,
compliance.,To,ensure,the,client's,cooperation,and,promote,independence,,the,nurse,should,inform,th
e,client,about,the,plan,for,moving,to,the,chair,(B),and,encourage,the,client,to,participate,by,pushing,th
e,IV,pole,when,walking,to,the,chair,(D).,The,nurse,should,assess,the,client's,blood,pressure,(F),prior,to,
mobilization,,which,can,cause,orthostatic,hypotension.,(C,and,E),are,not,indicated.
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,,,ANS,-,C
To,provide,moisture,and,loosen,the,necrotic,tissue,,the,eschar,should,be,covered,first,with,wet,to,mois
t,dressings,(C),,which,are,discontinued,and,then,a,hydrogel,alginate,can,be,placed,in,the,prepared,wou
nd,bed,to,prevent,further,damage,of,granulating,any,surrounding,tissue.,Although,a,hydrogel,(A),liquefi
es,necrotic,tissue,of,slough,and,rehydrates,the,wound,bed,,it,does,not,address,wicking,the,purulent,dra
,inage,from,the,wound.,Exudate,absorbers,(B),provide,a,moist,wound,surface,,absorb,exudate,,and,sup
port,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.
The,nurse,is,preparing,to,irrigate,a,client's,indwelling,urinary,catheter,using,an,open,technique.,What,a
ction,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.,,,ANS,-,B
To,irrigate,an,indwelling,urinary,catheter,,the,nurse,should,first,apply,gloves,,then,draw,up,the,irrigatin
g,solution,into,the,syringe,(B).,The,syringe,is,then,attached,to,the,catheter,and,the,fluid,instilled,,using,
aseptic,technique,(D).,Once,the,irrigating,solution,is,instilled,,the,client's,catheter,should,be,secured,to,
the,drainage,tubing,(C).,The,urinary,drainage,bag,can,be,emptied,(A),whenever,intake,and,output,meas
urement,is,indicated,,and,the,instilled,irrigating,fluid,can,be,subtracted,from,the,output,at,that,time.
While,caring,for,a,child,and,mother,from,Cambodia,,what,action,should,the,nurse,implement,to,accom
modate,the,clients',cultural,needs?
A),Speak,initially,with,the,oldest,family,member,to,show,respect.
B),Realize,that,Southeast,Asians,may,not,take,Western,medications.
C),Ask,the,husband,to,step,out,during,the,mother's,pelvic,examination.
D),Tell,the,family,that,planning,health,care,is,provided,in,private,with,the,client.,,,ANS,-,A
Members,of,the,Asian,culture,have,high,respect,for,others,,especially,those,in,positions,of,authority.,Ex
tended,family,members,need,to,be,included,in,the,nursing,care,plan,(A).,Southeast,Asians,do,not,neces
sarily,refuse,Western,medications,(B).,Asians,also,believe,that,touching,strangers,is,not,acceptable,,par
ticularly,health,professionals,whom,they,have,not,previously,known,,so,the,husband,should,be,allowed
,to,remain,with,his,wife,during,the,pelvic,exam,(C).,Provided,that,the,presence,of,other,family,member
s,is,not,harmful,to,the,client's,well-being,,(D),is,not,correct.
,The,nurse,removes,the,dressing,on,a,client's,heel,that,is,covering,a,pressure,sore,one-
inch,in,diameter,and,finds,that,there,is,straw-
colored,drainage,seeping,from,the,wound.,What,description,of,this,finding,should,the,nurse,include,in,t
he,client's,record?
A),Stage,1,pressure,sore,draining,sero-sanguineous,drainage.
B),Pressure,sore,at,bony,prominence,with,exudate,noted.
C),One-inch,pressure,sore,draining,serous,fluid.
D),Pressure,sore,on,heel,with,a,small,amount,of,purulent,drainage.,,,ANS,-,C
Serous,drainage,is,clear,watery,plasma,,so,(C),provides,accurate,documentation,based,on,the,informati
on,provided.,Information,to,stage,this,pressure,score,(A),is,not,provided,,and,sero-
sanguineous,drainage,is,pale,and,watery,with,a,combination,of,plasma,and,red,cells,,and,may,be,blood
-
streaked.,Exudate,(B),is,fluid,such,as,pus,and,serum.,Purulent,drainage,(D),is,thick,,yellow,,green,,or,br
own,indicating,the,presence,of,dead,or,living,organisms,and,white,blood,cells.
The,charge,nurse,assigns,a,nursing,procedure,to,a,new,staff,nurse,who,has,not,previously,performed,th
e,procedure.,What,action,is,most,important,for,the,new,staff,nurse,to,take?
A),Review,the,steps,in,the,procedure,manual.
B),Ask,another,nurse,to,assist,while,implementing,the,procedure.
C),Follow,the,agency's,policy,and,procedure.
D),Refuse,to,perform,the,task,that,is,beyond,the,nurse's,experience.,,,ANS,-,D
According,to,states',nurse,practice,acts,,it,is,the,responsibility,of,the,nurse,to,function,within,the,scope,
of,competency,(D),,and,in,this,case,safe,nursing,practice,constitutes,refusal,to,perform,the,procedure,b
ecause,of,a,lack,of,experience.,Although,state,mandates,,agency,policies,,and,continued,education,and,
experience,identify,tasks,that,are,within,the,scope,of,nursing,practice,,nurses,should,first,refuse,to,perf
orm,tasks,that,are,beyond,their,proficiency,,and,then,pursue,opportunities,to,enhance,their,competenc
y,(A,,B,,and,C).
A,male,client,with,venous,incompetence,stands,up,and,his,blood,pressure,subsequently,drops.,Which,fi
nding,should,the,nurse,identify,as,a,compensatory,response?
, ,
A),Bradycardia.
B),Increase,in,pulse,rate.
C),Peripheral,vasodilation.
D),Increase,in,cardiac,output.,,,ANS,-,B
When,postural,hypotension,occurs,,the,body,attempts,to,restore,arterial,pressure,by,stimulating,the,ba
ro-
receptors,to,increase,the,heart,rate,(B),,not,decrease,it,(A).,Peripheral,vasoconstriction,,not,dilation,(C),
,of,the,veins,and,arterioles,occurs,with,venous,incompetence,through,the,baro-
receptor,reflex.,A,decrease,in,cardiac,output,,not,an,increase,(D),,occurs,when,orthostatic,hypotension,
occurs.
A,client,with,Raynaud's,disease,asks,the,nurse,about,using,biofeedback,for,self-
management,of,symptoms.,What,response,is,best,for,the,nurse,to,provide?
A),The,responses,to,biofeedback,have,not,been,well,established,and,may,be,a,waste,of,time,and,mone
y.
B),Biofeedback,requires,extensive,training,to,retrain,voluntary,muscles,,not,involuntary,responses.
C),Although,biofeedback,is,easily,learned,,it,is,most,often,used,to,manage,exacerbation,of,symptoms.
D),Biofeedback,allows,the,client,to,control,involuntary,responses,to,promote,peripheral,vasodilation.,,,
ANS,-,D
Biofeedback,involves,the,use,of,various,monitoring,devices,that,help,people,become,more,aware,and,a
ble,to,control,their,own,physiologic,responses,,such,as,heart,rate,,body,temperature,,muscle,tension,,a
nd,brain,waves.,(D),is,an,accurate,statement,concerning,its,use,for,clients,with,Raynaud's,disease.,(A,,B
,,and,C),do,not,provide,correct,information,about,biofeedback.
A,female,client,who,has,breast,cancer,with,metastasis,to,the,liver,and,spine,is,admitted,with,constant,,
severe,pain,despite,around-the-
clock,use,of,oxycodone,(Percodan),and,amitriptyline,(Elavil),for,pain,control,at,home.,During,the,admis
sion,assessment,,which,information,is,most,important,for,the,nurse,to,obtain?
,
A),Sensory,pattern,,area,,intensity,,and,nature,of,the,pain.
