HESI – Fundamentals Questions Verified and Provided with A+
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When turning an immobile bedridden client B
without assistance, which action by the nurse best Rationale: Because the nurse can only stand on one side of the
bed, ensures client safety? bed rails should be up on the opposite side to ensure that the client
A. Securely grasp the client's arm and leg. does not fall out of bed. Option A can cause client injury to the skin or
B.Put bed rails up on the side of bed opposite joint. Options C and D are useful techniques while turning a client
but from the nurse. have less priority in terms of safety than use of the bed rails.
C. Correctly position and use a turn sheet.
D.Lower the head of the client's bed slowly.
The nurse identifies a potential for infection in a B
client with partial-thickness (second-degree) and Rationale: Careful handwashing technique is the single most effective
full-thickness (third-degree) burns. What intervention for the prevention of contamination to all clients. Option
A intervention has the highest priority in decreasing reverses the hypovolemia that initially accompanies burn
trauma but is the client's risk of infection? not related to decreasing the proliferation of infective organisms.
A. Administration of plasma expanders Options C and D are recommended by various burn centers as possible
B.Use of careful handwashing technique ways to reduce the chance of infection. Option B is a proven technique
C. Application of a topical antibacterial cream to prevent infection.
D.Limiting visitors to the client with burns
The nurse is aware that malnutrition is a common A
problem among clients served by a community Rationale: Long-term protein deficiency is required to cause
health clinic for the homeless. Which laboratory significantly lowered serum albumin levels. Albumin is made by the
liver value is the most reliable indicator of chronic only when adequate amounts of amino acids (from protein breakdown)
protein malnutrition? are available. Albumin has a long half-life, so acute protein loss
does
A. Low serum albumin level not significantly alter serum levels. Option B is a serum protein with a
B.Low serum transferrin level half-life of only 8 to 10 days, so it will drop with an acute protein
C. High hemoglobin level deficiency. Options C and D are not clinical measures of protein
D.High cholesterol level malnutrition.
In completing a client's preoperative routine, the C
nurse finds that the operative permit is not signed. Rationale: The surgeon should be informed immediately that the
permit The client begins to ask more questions about the is not signed. It is the surgeon's responsibility to explain
the procedure surgical procedure. Which action should the nurse to the client and obtain the client's signature
on the permit. Although take next? the nurse can witness an operative permit, the procedure must first be
A. Witness the client's signature to the permit. explained by the health care provider or surgeon, including answering
B. Answer the client's questions about the surgery. the client's questions.
The client's questions should be addressed before
C. Inform the surgeon that the operative permit is the permit is signed.
not signed and the client has questions about the
surgery.
D.Reassure the client that the surgeon will
answer any questions before the anesthesia is
administered.
The nurse is assessing several clients prior to B
surgery. Which factor in a client's history poses the Rationale:
greatest threat for complications to occur during Anticoagulants increase the risk for bleeding during surgery, which
can surgery? pose a threat for the development of surgical complications. The
health
A. Taking birth control pills for the past 2 years care provider should be informed that the client is taking these drugs.
B. Taking anticoagulants for the past year Although clients who take birth
control pills may be more susceptible to
C. Recently completing antibiotic therapy the development of thrombi, such problems usually occur
D.Having taken laxatives PRN for the last 6 months postoperatively. A client with option C or D is at less of a surgical risk
, than with option B.
When assisting a client from the bed to a chair, B
which procedure is best for the nurse to follow? Rationale: Option B describes the correct positioning of the nurse and
A. Place the chair parallel to the bed, with its back affords the nurse a wide base of support while stabilizing the
client's toward the head of the bed and assist the client in knees when assisting to a standing position. The chair
should be placed moving to the chair. at a 45-degree angle to the bed, with the back of the chair toward the
B.With the nurse's feet spread apart and knees head of the bed. Clients should never be lifted under the axillae; this
aligned with the client's knees, stand and pivot the could damage nerves and strain the nurse's back. The client should
be
client into the chair. instructed to use the arms of the chair and should never place his or her
C. Assist the client to a standing position by gently arms around the nurse's neck; this places undue stress on the nurse's
lifting upward, underneath the axillae. neck and back and increases the risk for a fall.
D.Stand beside the client, place the client's
arms around the nurse's neck, and gently
move the
client to the chair.
Which step(s) should the nurse take when A, B
administering ear drops to an adult client? (Select Rationale: The correct answers (A and B) are the appropriate
all that apply.) administration of ear drops. The dropper should be held 1 cm (½ inch)
A. Place the client in a side-lying position. above the ear canal (C). A cotton ball should be placed in the
B.Pull the auricle upward and outward. outermost canal (D). The auricle is pulled down and back for a child
C. Hold the dropper 6 cm above the ear canal. younger than 3 years of age, but not an adult (E).
D.Place a cotton ball into the inner canal.
E.Pull the auricle down and back.
The nurse is instructing a client in the proper use of B
a metered-dose inhaler. Which instruction should Rationale: The medication should be inhaled through the mouth
the nurse provide the client to ensure the optimalsimultaneously with compression of the inhaler. This will facilitate the
benefits from the drug? desired destination of the aerosol medication deep in the lungs for an
A. "Fill your lungs with air through your mouth and optimal bronchodilation effect. Options A, C, and D do not allow
for then compress the inhaler." deep lung penetration.
B."Compress the inhaler while slowly breathing
in through your mouth."
C. "Compress the inhaler while inhaling
quickly through your nose."
D."Exhale completely after compressing
the inhaler and then inhale."
A 20-year-old female client with a noticeable body D
odor has refused to shower for the last 3 days. She Rationale: Because a shower is most beneficial for the client in
terms of states, "I have been told that it is harmful to bathe hygiene, the client should receive teaching first,
respecting any
during my period." Which action should the nurse personal beliefs such as cultural or spiritual values. After client
teaching, take first? the client may still choose option A or B. Brochures reinforce the
A. Accept and document the client's wish to refrain
teaching. from bathing.
B.Offer to give the client a bed bath, avoiding the
perineal area.
C. Obtain written brochures about menstruation to
give to the client.
D.Teach the importance of personal hygiene
during menstruation with the client.
, While reviewing the side effects of a newly A
prescribed medication, a 72-year-old client notes Rationale: Option A offers an open-ended question most relevant to the
that one of the side effects is a reduction in sexual client's statement. Option B does not offer the client the opportunity
to drive. Which is the best response by the nurse?express concerns. Options C and D are even less relevant to the
client's
A. "How will this affect your present sexual statement.
activity?"
B."How active is your current sex life?"
C. "How has your sex life changed as you
have become older?"
D."Tell me about your sexual needs as an
older adult."
The nurse is using the Glasgow Coma Scale to .A
perform a neurologic assessment. A comatose Rationale: The client has demonstrated a purposeful response to
pain, client winces and pulls away from a painful which should be documented as such. Response to painful stimulus is
stimulus. Which action should the nurse take next? assessed after response to verbal stimulus, not before. There is no
A. Document that the client responds to painful indication for placing the client on seizure precautions. Reporting
stimulus. decorticate posturing to the health care provider is nonpurposeful
B.Observe the client's response to verbal movement.
stimulation.
C. Place the client on seizure precautions for 24
hours.
D.Report decorticate posturing to the health care
provider
The nurse plans to administer diazepam, 4 mg IV B
push, to a client with severe anxiety. How many Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
milliliters should the nurse administer? (Round to
the nearest tenth.)
A. 0.2 mL
B.0.8 mL
C. 1.25 mL
D.2.0 mL
The nurse prepares to insert a nasogastric tube in A, D
a client with hyperemesis who is awake and alert. Rationale:
Which intervention(s) is(are) correct? (Select all (A and D) are the correct steps to follow during nasogastric intubation.
that apply.) Only the unconscious or obtunded client should be placed in a
left
A. Place the client in a high Fowler position. side-lying position (B). The tube should be measured from the tip of the
B.Help the client assume a left side-lying position. nose to behind the ear and then from behind the ear to the xiphoid
C. Measure the tube from the tip of the nose to the process (C). The neck should only be extended back prior to the tube
umbilicus. passing the pharynx and then the client should be instructed to position
D.Instruct the client to swallow after the tube has the neck forward (E).
passed the pharynx.
E.Assist the client in extending the neck back
so the tube may enter the larynx.