Fundamentals HESI

1. Older female client can't sleep at night. Nurse recommends SATA A. Take afternoon nap B. Ask HCP for prescription of mild sedative at bedtime C. Establish regular time for getting up and going to bed D. Drink whiskey, water and honey before bed E. Avoid drinking caffeine before bedtime - Correct Ans: C, E 2. The nurse has been alerted by the EMR when scanning the dispensed medication that the dosage is two times higher than the prescribed dose. The nurse should: A. Report mismatch of prescription and available dosages B. Withhold medication until exact dose is available C. Ask pharmacy if another dose can be dispensed D. Calculate dose on hand to match the prescribed dose - Correct Ans: D 3. A patient diagnosed with small bowel obstruction refuses surgery. The nurse should: A. Assess client needs for antiemetics and pain medications B. Prepare nasogastric tube compress C. Sent patient to CT abdominal scan D. Notify HCP that patient refuses surgery - Correct Ans: D 4. What is the most important factor for obesity referral? A. BMI 35 B. Client expressed desire to lose 50 pounds C. Body weight is 10% over ideal weight D. Daily calorie intake is 3,500 - Correct Ans: A 5. An elderly patient returns to the clinic for chronic pain management. He is prescribed MS Contin PO Q12H. He states that he only takes it when the pain is so severe that he can't sleep. A. Long time use of opioids may cause drug addiction B. Take medication Q12H as prescribed C. Teach alternative methods for pain management D. Continue taking MS Contin for severe pain. - Correct Ans: B 6. IM ventrogluteal landmark A. Upper outer quadrant of buttock B. Deltoid C. Knee and greater trochanter D. Greater trochanter and anterior superior iliac spine - Correct Ans: D 7. A client with a nasogastric tube is receiving low intermittent suction and is complaining of dry mouth. What should the nurse implement? A. Tell the client that the mucosa must stay dry to prevent aspiration B. Turn off suction so that the client can rinse his mouth with cold water C. Provide oral sponge toothettes so the client can clean and moisten his mouth D. Instill 50 mL of normal saline and clamp - Correct Ans: C 8. A client who is 12 days post op complains of thoracic incisional pain 2 hours after he received his pain medication. The HCP has been called. What should the nurse do next? A. Guided imagery and deep breathing B. Turn on a T.V. show and music for distraction C. Put a hot device on the area D. Provide a 20 minute back massage - Correct Ans: A 9. A post-op patient is grimacing when moving from bed to chair but denies pain. What should the nurse do next? A. Administer pain medication PRN B. Review his pain medications that are prescribed C. Monitor patient's nonverbal actions D. Ask what is making him grimace - Correct Ans: D 10. A client is on a mechanical soft diet and is constipated. He requests for prune juice. The nurse should: A. Restrict fluid B. Initiate bowel training protocol C. Advance to regular diet D. Offer to warm up the prune juice - Correct Ans: D 11. The nurse is assessing a client's ability to perform activities of daily living (ADL) safely. The client has steady gait and is able to ambulate from the door to the bed with full ROM. The nurse should: A. Teach the client to take shorter strides for better balance B. Record client's ability to perform ADL safely C. Initiate fall risk protocol D. Determine client's activity tolerance - Correct Ans: D 12. A patient is demonstrating diaphragmatic breathing by holding her abdomen while inhaling and removing her hands during exhalation. A. The demonstration was successful B. The hands do not need be on the abdomen, but the demonstration was still correct C. Keep light pressure on abdomen and cough after inspiration D. Expand abdomen during inspiration and let the abdomen sink during exhalation - Correct Ans: D 13. Highest priority? A. Impaired bed mobility B. Fluid volume deficit C. Bowel incontinence D. Caregiver role strain - Correct Ans: B 14. The computer system shuts down while the nurse was inputting client data. What should the nurse do next? A. Print EMR from backup server B. Wait for notification that the EMR is rebooted C. Identify information as late entry D. Notify IT - Correct Ans: D 15. The student nurse assesses an adult client's TM by pulling the ear up and back. The preceptor: A. Provides positive reinforcement to the student nurse for using correct technique B. Tells the student nurse that the ear should be pulled down - Correct Ans: A 16. How should the nurse instruct the mother of an adolescent with Diabetes Type 1 to inject insulin? [Picture of injection at deltoid] A. Correct her to the proper injection site B. Instruct mother how to insert needle with dart-like motion - Correct Ans: B 17. A client in pre-op reports "I feel funny all over...my belly feels weird" right before surgery. What is the nurse's best response? A. "Describe what your HCP told you regarding your surgery." B. "You say you feel funny everywhere. Is it located mostly in your stomach?" C. "Are you becoming frightened?" D. "Tell me more about the feelings in your belly." - Correct 18. Which related data should be obtained if a client is wheezing? A. Radiates to other parts of the body B. Heart sounds C. Body temperature D. Precipitating factors - Correct Ans: D 19. Picture of a nurse about to open an ampule. What should the nurse do next? A. Clean neck of ampule with alcohol B. Position gauze around neck of ampule C. Apply clean gloves before breaking the ampule open D. Snap neck away from hands - Correct Ans: B 20. UAP is not fitted for a respirator mask and requests to be re-assigned from a client with droplet precautions. The charge nurse should: A. Before changing assignments, check to see which nurses are fitted for the respirators B. Send UAD to get fitted for the respirator immediately so that she can return to take care of the patient C. Tell the UAP that she can wear a standard mask during vitals and use a respirator mask for other tasks D. Tell the UAP that a standard face mask is sufficient - Correct Ans: D 21. Patient complains that he hates how his boss orders him around and how he doesn't listen to his ideas. What is the nurse's best response? A. "I'm sure that it will get better with time." B. "It must be difficult for you to work in a place that makes you feel so bad." C. "How do you feel when your boss doesn't listen to you?" D. "You should change how you interact with your boss." - Correct Ans: C 22. A Native American client complains of a