HESI FUNDAMENTALS PRACTICE EXAM EXAM TEST BANK WITH ALL VERSIONS OF THE EXAM WITH ALLMODULES COVERED | ACCURATE AND VERIFIED QUESTIONS AND ANSWERS FOR GUARANTEED PASS| LATEST UPDATE

The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? A) Infuse normal saline at a keep vein open rate. B) Discontinue the IV and flush the port with heparin. C) Infuse 10% dextrose and water at 54 mL/hour. D) Obtain a stat blood glucose level and notify the healthcare provider. • Correct Answer: C • Rationale: TPN contains high concentrations of glucose. Abrupt discontinuation can cause rebound hypoglycemia. Infusing 10% dextrose in water at the same rate maintains glucose delivery until the next TPN solution is available. Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm. B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter. C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size. D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. • Correct Answer: B • Rationale: Flat, discolored areas less than 1 cm are macules. The nurse should describe the appearance objectively rather than using a diagnostic label. Vesicles (A) are fluidfilled, papules (C) are elevated, and petechiae (D) are pinpoint hemorrhages that do not itch. At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? A) "It is normal to feel angry and depressed, but the sooner you deal with this surgery, the better you will feel." B) "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." C) "It is OK if you don't want to talk about your surgery. I will be available when you are ready." D) "I will ask a woman who has had a mastectomy to come by and share her experiences with you." • Correct Answer: C • Rationale: This response respects the client's readiness to cope, provides support without pressure, and leaves the door open for future discussion. Options A and B are judgmental and demanding. Option D may be helpful later but dismisses the nurse's immediate role. The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A) Scrambled eggs, bacon, toast, and orange juice B) Ham sandwich, potato chips, and cola C) Skim milk, turkey salad, roll, and vanilla ice cream D) Cheese omelet, sausage links, and whole milk • Correct Answer: C • Rationale: Skim milk, turkey salad (turkey is lower in sodium than processed meats), a roll, and vanilla ice cream are all relatively low in sodium compared to bacon, ham, cheese, sausage, and processed snacks. The nurse prepares a 1000 mL IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A) 10 B) 15 C) 21 D) 30 • Correct Answer: C • Rationale: Calculate total drops: 1000 mL × 10 drops/mL = 10,000 drops. Total minutes = 8 hours × 60 minutes = 480 minutes. Drops per minute = 10,000 / 480 = approximately 21 drops/minute. An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A) Prone B) Fowler's C) Sim's D) Supine • Correct Answer: B • Rationale: Fowler's position (semi-upright) uses gravity to help prevent aspiration during tube feeding. Prone (A) and supine (D) increase aspiration risk. Sim's (C) is a side-lying position not optimal for feeding. Which action is the most important to implement when donning sterile gloves? A) Maintain thumb at a ninety degree angle. B) Hold hands with fingers down while gloving. C) Keep gloved hands above the elbows. D) Put the glove on the dominant hand first. • Correct Answer: C • Rationale: Once gloved, hands must remain above waist level to maintain sterility. Options A, B, and D are not essential for maintaining asepsis. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? A) Avoid any types of sprays, powders, and perfumes. B) Wearing a mask while cleaning will not help to avoid allergens. C) Purchase any type of clothing, but be sure it is washed before wearing it. D) Pollen count is related to hay fever, not to allergens. • Correct Answer: A • Rationale: Sprays, powders, and perfumes contain chemicals and particles that can trigger allergic reactions. Avoidance is key. Option B is incorrect; masks do help. Option C is incomplete without specifying natural fibers. Option D is false; pollen is a common allergen. A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? A) "In 8 weeks you will be able to bend at the waist to reach items on the floor." B) "Place a pillow between your knees while lying in bed to prevent hip dislocation." C) "It is safe to use a walker to get out of bed, but you need assistance when walking." D) "Take pain medication 30 minutes after your physical therapy sessions." • Correct Answer: B • Rationale: Abduction pillows or pillows between the knees maintain hip abduction and prevent dislocation, a risk for 6-12 months post-surgery. Bending at the waist (A) is typically prohibited. Clients need assistance until stable (C). Pain medication should be taken before therapy, not after (D). The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A) Encourage the client to cough to help loosen secretions. B) Advise the client to increase the intake of oral fluids. C) Rotate the suction catheter to obtain any remaining secretions. D) Re-oxygenate the client before attempting to suction again. • Correct Answer: D • Rationale: Suctioning removes oxygen along with secretions. After each pass, the client must be re-oxygenated to prevent hypoxia. Options A, B, and C are not the immediate priority. A client's infusion of normal saline infiltrated earlier today, and approximately 500 mL of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take? A) Ask about any past history of drug abuse or addiction. B) Measure the pulse volume and capillary refill distal to the infiltration. C) Compress the infiltrated tissue to measure the degree of edema. D) Evaluate the extent of ecchymosis over the forearm area. • Correct Answer: B • Rationale: Severe pain and significant infiltration raise concern for compartment syndrome. Assessing distal pulses and capillary refill evaluates circulatory compromise, which is the priority. Option A is premature; C and D are less urgent than circulatory assessment. The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? A) Remain calm with the client and record abnormal results in the chart. B) Notify the medication nurse immediately if the pulse or blood pressure is low. C) Report the results of the vital signs to the nurse. D) Reassure the client that the vital signs are normal. • Correct Answer: C • Rationale: The UAP should report vital sign measurements to the nurse, who is responsible for interpretation and decision-making. UAPs should not interpret, record abnormal results independently, or make clinical judgments. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A) "That means you have derived the maximum benefit, and the heat can be removed." B) "Your blood vessels are becoming dilated and removing the heat from the site." C) "We will increase the temperature 5 degrees when the pad no longer feels warm." D) "The body's receptors adapt over time as they are exposed to heat." • Correct Answer: D • Rationale: Thermal adaptation occurs 20-30 minutes after heat application as sensory receptors become less responsive. Options A, B, and C provide incorrect or unsafe information. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? A) Loosen the right wrist restraint. B) Apply a pulse oximeter to the right hand. C) Compare hand color bilaterally. D) Palpate the right radial pulse. • Correct Answer: A • Rationale: Blue fingers indicate compromised circulation. The priority is to immediately loosen the restraint to restore blood flow. Options C and D are assessments but do not take priority over intervention. Pulse oximetry (B) is not the priority for mechanical compression. An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A) A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B) The nurse assigned to care for the client who was at lunch at the time of the fall. C) The nurse who transferred the client to the chair when the fall occurred. D) The charge nurse who completed rounds 30 minutes before the fall occurred. • Correct Answer: C • Rationale: Malpractice requires duty, breach of duty, causation, and injury. The nurse who was transferring the client at the time of the fall owed a duty of care, and the injury occurred during that care, establishing direct causation. Options A, B, and D lack evidence of direct breach causing the injury. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? A) Tell the UAP to use a larger cuff at the next scheduled assessment. B) Reassess the client's blood pressure using a larger cuff. C) Have the unit educator review this procedure with the UAPs. D) Teach the UAP the correct technique for assessing blood pressure. • Correct Answer: B • Rationale: A cuff that is too small can falsely elevate blood pressure readings. Ensuring an accurate measurement is the priority; the nurse should reassess with the correct cuff size now. Options A, C, and D address education but not the immediate need for accurate data. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? A) Massage any reddened areas for at least five minutes. B) Encourage active range of motion exercises on extremities. C) Position the client laterally, prone, and dorsally in sequence. D) Gently lift the client when moving into a desired position. • Correct Answer: D • Rationale: Lifting rather than dragging prevents shearing forces that damage skin. Reddened areas should not be massaged (A). Active ROM may be limited on the affected leg (B). Prone positioning (C) is contraindicated with a hip fracture. The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? A) Place the chair at a right angle to the bed on the client's left side before moving. B) Assist the client to a standing position, then place the right hand on the armrest. C) Have the client place the left foot next to the chair and pivot to the left before sitting. D) Move the chair parallel to the right side of the bed, and stand the client on the right foot. • Correct Answer: D • Rationale: The transfer should use the client's stronger (right) side for weight-bearing. Positioning the chair on the right allows the client to pivot onto the stronger leg. Options A, B, and C place weight on the weaker left side, increasing fall risk. An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A) Reaffirm the client's desire for no resuscitative efforts. B) Transfer the client to a hospice inpatient facility. C) Prepare the family for the client's impending death. D) Notify the healthcare provider of the family's request. • Correct Answer: D • Rationale: Hospice care requires a healthcare provider's order based on a terminal prognosis. The nurse must first notify the provider to initiate the referral. Options A, B, and C come after the provider's involvement. After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A) Determine the etiology of the problem. B) Prioritize nursing care interventions. C) Plan appropriate interventions. D) Collaborate with the client to set goals. • Correct Answer: A • Rationale: After identifying a problem, the nurse must first determine its etiology (cause) to guide appropriate interventions, goal-setting, and prioritization. Options B, C, and D follow after the cause is understood.