Nightingale College BSN 246
HESI Fundamentals Exam Practice
Questions – Comprehensive Nursing
Review & Test Preparation
Terms in this set (72)
,A male client has a nursing diagnosis of
D
"spiritual distress." What intervention is best
for the nurse to implement when caring
Rationale: The most beneficial nursing intervention is to use
for this client?
nonjudgmental reflective listening techniques, to allow the
client to feel comfortable expressing his concerns (D). (A and
A.) Use distraction techniques during
B) are not therapeutic. The client should be consulted before
times of spiritual stress and crisis.
implementing (C).
B.)Reassure the client that his faith will
be regained with time and support.
C.) Consult with the staff chaplain and
ask that the chaplain visit with the
client.
D.)Use reflective listening techniques
when the client expresses spiritual
doubts.
The nurse removes the dressing on a client's
C
heel that is covering a pressure sore
one-inch in diameter and finds that
Rationale: Serous drainage is clear watery plasma, so (C)
there is
provides accurate documentation based on the information
straw-colored drainage seeping from the
provided. Information to stage this pressure score (A) is not
wound. What description of this finding
provided, and sero-sanguineous drainage is pale and watery
should the nurse include in the
with a combination of plasma and red cells, and may be
client's record?
blood-streaked. Exudate (B) is fluid such as pus and serum.
Purulent drainage (D) is thick, yellow, green, or brown
A.) Stage 1 pressure sore draining sero-
indicating the presence of dead or living organisms and white
sanguineous drainage.
blood cells.
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.
The nurse is preparing to give a
B
client dehydration IV fluids
delivered at a continuous rate of
Rationale: A cassette pump (B) should be used to accurately
175 ml/hour. Which infusion device
deliver large volumes of fluid over longer periods of time with
should the nurse use?
extreme precision, such as ml/hour. A syringe pump (A) is
accurate for low-dose continuous infusion of low-dose
A.) Portable syringe pump.
medication at a basal rate, but not large fluid volume
B.) Cassette infusion pump.
replacement. Volumetric (C) and nonvolumetric (D)
C.)Volumetric controller.
controllers count drops/minute to administer fluid volume and
D.)Nonvolumetric controller.
are inherently inaccurate because of variation in drop size.
How should the nurse handle linens that D.) Ask the housekeeping staff to pick up the soiled linen
are soiled with incontinent feces? from the dirty utility room.
A.) Put the soiled linens in an isolation
bag, then place it in the dirty linen
hamper.
B.)Place an isolation hamper in the
client's room and discard the linens in
it.
C.) Place the soiled linens in a pillow
case and deposit them in the dirty linen
hamper.
, C
Rationale: The nurse should be careful
to keep the soiled linens from
contaminating the fresh linens, and
should handle the soiled linens like any
other dirty linen (C). (A, B, and D) are not
indicated.
HESI Fundamentals Exam Practice
Questions – Comprehensive Nursing
Review & Test Preparation
Terms in this set (72)
,A male client has a nursing diagnosis of
D
"spiritual distress." What intervention is best
for the nurse to implement when caring
Rationale: The most beneficial nursing intervention is to use
for this client?
nonjudgmental reflective listening techniques, to allow the
client to feel comfortable expressing his concerns (D). (A and
A.) Use distraction techniques during
B) are not therapeutic. The client should be consulted before
times of spiritual stress and crisis.
implementing (C).
B.)Reassure the client that his faith will
be regained with time and support.
C.) Consult with the staff chaplain and
ask that the chaplain visit with the
client.
D.)Use reflective listening techniques
when the client expresses spiritual
doubts.
The nurse removes the dressing on a client's
C
heel that is covering a pressure sore
one-inch in diameter and finds that
Rationale: Serous drainage is clear watery plasma, so (C)
there is
provides accurate documentation based on the information
straw-colored drainage seeping from the
provided. Information to stage this pressure score (A) is not
wound. What description of this finding
provided, and sero-sanguineous drainage is pale and watery
should the nurse include in the
with a combination of plasma and red cells, and may be
client's record?
blood-streaked. Exudate (B) is fluid such as pus and serum.
Purulent drainage (D) is thick, yellow, green, or brown
A.) Stage 1 pressure sore draining sero-
indicating the presence of dead or living organisms and white
sanguineous drainage.
blood cells.
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.
The nurse is preparing to give a
B
client dehydration IV fluids
delivered at a continuous rate of
Rationale: A cassette pump (B) should be used to accurately
175 ml/hour. Which infusion device
deliver large volumes of fluid over longer periods of time with
should the nurse use?
extreme precision, such as ml/hour. A syringe pump (A) is
accurate for low-dose continuous infusion of low-dose
A.) Portable syringe pump.
medication at a basal rate, but not large fluid volume
B.) Cassette infusion pump.
replacement. Volumetric (C) and nonvolumetric (D)
C.)Volumetric controller.
controllers count drops/minute to administer fluid volume and
D.)Nonvolumetric controller.
are inherently inaccurate because of variation in drop size.
How should the nurse handle linens that D.) Ask the housekeeping staff to pick up the soiled linen
are soiled with incontinent feces? from the dirty utility room.
A.) Put the soiled linens in an isolation
bag, then place it in the dirty linen
hamper.
B.)Place an isolation hamper in the
client's room and discard the linens in
it.
C.) Place the soiled linens in a pillow
case and deposit them in the dirty linen
hamper.
, C
Rationale: The nurse should be careful
to keep the soiled linens from
contaminating the fresh linens, and
should handle the soiled linens like any
other dirty linen (C). (A, B, and D) are not
indicated.
