HESI Nursing Fundamentals
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The nurse removes the Answer: C
dressing on a client's heel Rationale
that is covering a pressure Serous drainage is clear watery plasma, so (C)
sore one-inch in diameter provides accurate documentation based on the
and finds that there is information provided. Information to stage this
straw-colored drainage pressure score (A) is not provided, and sero-
seeping from the wound. sanguineous drainage is pale and watery with a
What description of this combination of plasma and red cells, and may be
finding should the nurse blood-streaked. Exudate (B) is fluid such as pus and
include in the client's serum. Purulent drainage (D) is thick, yellow, green, or
record? brown indicating the presence of dead or living
organisms and white blood cells.
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.
,As the nurse prepares the Answer: C
equipment to be used to Rationale
start an IV on a 4-year-old A 4-year-old typically has a vivid imagination and
boy in the treatment room, lacks concrete thinking abilities. The mother's
he cries continuously. assistance (C) can provide a stabilizing presence to
What intervention should help soothe the preschooler, who may perceive the
the nurse implement? invasive procedure as mutilating. To preserve the
child's sense of security associated with the hospital
A) Take the child back to room, it is best to perform difficult or painful
his room. procedures in another area (A). (B) may be necessary
B) Recruit others to to prevent injury if the child is unable to cooperate
restrain the child. with the mother's coaxing. (D) is best done before
C) Ask the mother to be going to the treatment room when the child feels less
present to soothe the threatened.
child.
D) Show the child how to
manipulate the equipment.
,On the third postoperative Answer: B
day following thoracic Rationale
surgery, a client reports Prune juice is a natural laxative that stimulates
feeling constipated. Which peristalsis, and warming the prune juice (B) facilitates
intervention should the peristalsis. (A) is also helpful in promoting peristalsis
nurse implement to but is less likely to relieve the client's constipation. (C)
promote bowel reduces discomfort during ambulation, but will not
elimination? help relieve the client's constipation. Defecation is not
painful following most surgeries, and many analgesics
A) Remind the client to used postoperatively cause constipation, so (D) is
turn every two hours while contraindicated.
lying in bed.
B) Provide warm prune
juice before the client
goes to bed at night.
C) Teach the client to
splint the incision while
walking to the bathroom.
D) Administer an analgesic
before the client attempts
to defecate.
, To obtain the most Answer: D
complete assessment data Rationale
for a client with chronic A client with chronic pain is more likely to have
pain, which information adapted physiologically to vital sign changes,
should the nurse obtain? localization or intensity, so pain assessment should
focus on any interference with daily activities (D), such
A) Can you describe as sleep, relationships with others, physical activity,
where your pain is the and emotional well-being. Exacerbation of acute
most severe? symptoms, such as pain distribution, patterns,
B) What is your pain intensity, and descriptors elicit specific assessment
intensity on a scale of 1 to findings, whereas (A, B, and C) are limiting, closed-
10? end questions, and can be answered with a yes, no, or
C) Is your pain best a number.
described as aching,
throbbing, or sharp?
D) Which activities during
a routine day are
impacted by your pain?
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The nurse removes the Answer: C
dressing on a client's heel Rationale
that is covering a pressure Serous drainage is clear watery plasma, so (C)
sore one-inch in diameter provides accurate documentation based on the
and finds that there is information provided. Information to stage this
straw-colored drainage pressure score (A) is not provided, and sero-
seeping from the wound. sanguineous drainage is pale and watery with a
What description of this combination of plasma and red cells, and may be
finding should the nurse blood-streaked. Exudate (B) is fluid such as pus and
include in the client's serum. Purulent drainage (D) is thick, yellow, green, or
record? brown indicating the presence of dead or living
organisms and white blood cells.
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.
,As the nurse prepares the Answer: C
equipment to be used to Rationale
start an IV on a 4-year-old A 4-year-old typically has a vivid imagination and
boy in the treatment room, lacks concrete thinking abilities. The mother's
he cries continuously. assistance (C) can provide a stabilizing presence to
What intervention should help soothe the preschooler, who may perceive the
the nurse implement? invasive procedure as mutilating. To preserve the
child's sense of security associated with the hospital
A) Take the child back to room, it is best to perform difficult or painful
his room. procedures in another area (A). (B) may be necessary
B) Recruit others to to prevent injury if the child is unable to cooperate
restrain the child. with the mother's coaxing. (D) is best done before
C) Ask the mother to be going to the treatment room when the child feels less
present to soothe the threatened.
child.
D) Show the child how to
manipulate the equipment.
,On the third postoperative Answer: B
day following thoracic Rationale
surgery, a client reports Prune juice is a natural laxative that stimulates
feeling constipated. Which peristalsis, and warming the prune juice (B) facilitates
intervention should the peristalsis. (A) is also helpful in promoting peristalsis
nurse implement to but is less likely to relieve the client's constipation. (C)
promote bowel reduces discomfort during ambulation, but will not
elimination? help relieve the client's constipation. Defecation is not
painful following most surgeries, and many analgesics
A) Remind the client to used postoperatively cause constipation, so (D) is
turn every two hours while contraindicated.
lying in bed.
B) Provide warm prune
juice before the client
goes to bed at night.
C) Teach the client to
splint the incision while
walking to the bathroom.
D) Administer an analgesic
before the client attempts
to defecate.
, To obtain the most Answer: D
complete assessment data Rationale
for a client with chronic A client with chronic pain is more likely to have
pain, which information adapted physiologically to vital sign changes,
should the nurse obtain? localization or intensity, so pain assessment should
focus on any interference with daily activities (D), such
A) Can you describe as sleep, relationships with others, physical activity,
where your pain is the and emotional well-being. Exacerbation of acute
most severe? symptoms, such as pain distribution, patterns,
B) What is your pain intensity, and descriptors elicit specific assessment
intensity on a scale of 1 to findings, whereas (A, B, and C) are limiting, closed-
10? end questions, and can be answered with a yes, no, or
C) Is your pain best a number.
described as aching,
throbbing, or sharp?
D) Which activities during
a routine day are
impacted by your pain?
