HESI FUNDAMENTALS PRACTICE
EXAM #1 QUESTIONS & DETAILED
SOLUTIONS RATED 100% CORRECT
A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states
that she's ready to go home to die. What intervention should the nurse initiate? - CORRECT
ANSWER Evaluate the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot document
until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives &
DNR are not necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical
procedure. Which laboratory test indicates client's protein status for the longest length of time?
- CORRECT ANSWER Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance with bathing? -
CORRECT ANSWER "I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces? - CORRECT ANSWER
Place the soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest priority? - CORRECT
ANSWER Impaired gas exchange
, The nurse assesses an immobile, elderly male client & determines that his blood pressure is
138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last
hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment
findings , what nursing action is most important for the nurse to implement? - CORRECT
ANSWER Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring.
The home health nurse visits an elderly female client who had a brain attack 3 months ago & is
now able to ambulate with the assistance of a quad cane. Which assessment finding has the
greatest implications for this client's care? - CORRECT ANSWER The nurse notes there are
numerous scatter rugs throughout the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter &
finds that there is straw-colored drainage seeping from the wound. What description of this
finding should the nurse include in the client's record? - CORRECT ANSWER One-inch pressure
sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to administer this
Rx? - CORRECT ANSWER 0800, 1200, 1600, 2000
The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to
tolerate a higher level of pain? - CORRECT ANSWER 1 55y/o woman who has had moderate low
back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been relieved makes it
easier for the client to interpret the pain sensation and, as a result, the client is better prepared
to take steps to relieve the pain. All other clients are having new experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt
to have my tonsils & adenoids taken out?" Which response is best for the nurse to provide? -
CORRECT ANSWER "It may hurt, but we'll give you medicine to help you feel better."
EXAM #1 QUESTIONS & DETAILED
SOLUTIONS RATED 100% CORRECT
A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states
that she's ready to go home to die. What intervention should the nurse initiate? - CORRECT
ANSWER Evaluate the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot document
until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives &
DNR are not necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical
procedure. Which laboratory test indicates client's protein status for the longest length of time?
- CORRECT ANSWER Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance with bathing? -
CORRECT ANSWER "I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces? - CORRECT ANSWER
Place the soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest priority? - CORRECT
ANSWER Impaired gas exchange
, The nurse assesses an immobile, elderly male client & determines that his blood pressure is
138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last
hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment
findings , what nursing action is most important for the nurse to implement? - CORRECT
ANSWER Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring.
The home health nurse visits an elderly female client who had a brain attack 3 months ago & is
now able to ambulate with the assistance of a quad cane. Which assessment finding has the
greatest implications for this client's care? - CORRECT ANSWER The nurse notes there are
numerous scatter rugs throughout the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter &
finds that there is straw-colored drainage seeping from the wound. What description of this
finding should the nurse include in the client's record? - CORRECT ANSWER One-inch pressure
sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to administer this
Rx? - CORRECT ANSWER 0800, 1200, 1600, 2000
The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to
tolerate a higher level of pain? - CORRECT ANSWER 1 55y/o woman who has had moderate low
back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been relieved makes it
easier for the client to interpret the pain sensation and, as a result, the client is better prepared
to take steps to relieve the pain. All other clients are having new experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt
to have my tonsils & adenoids taken out?" Which response is best for the nurse to provide? -
CORRECT ANSWER "It may hurt, but we'll give you medicine to help you feel better."
