Hesi Fundamentals Questions and Answers

Hesi Fundamentals Questions and Answers When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A: Apply the blood pressure cuff securely. B: Record the client's pulse rate and rhythm. C: Position the client supine for a few minutes. D: Assist client to stand at bedside. C: Position the client supine for a few minutes. The home health nurse is reviewing the personal care of an elderly client who lives alone. Which client assessment findings indicate the need to assign the UAP to provide routine foot care and file the client's toenails?(SATA) A: Syncope when bending. B: Hand tremors. C: Diminished visual acuity. D: Urinary incontinence. E: Shuffling gait. A, B, C An older woman with end-stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What actions should the nurse take first? A: Discuss with the client her meaning of heroic measures. B: Obtain a DNR. C: Set up a family conference to discuss the client. D: Consult the palliative care team about the client's care. A: Discuss with the client her meaning of heroic measures. **When evaluating the effectiveness of a client's nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A: Modify the nursing interventions to achieve the client's goals. B: Determine if the expected outcomes were realistic. C: Review related professional standards of care. D: Obtain current client data to compare with expected outcomes. D: Obtain current client data to compare with expected outcomes. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the UAP who is assisting with the client's care?(SATA) A: Instruct the client about signs of orthostatic hypertension. B: Determine if the client needs to have a gait belt applied. C: Measure the client's vital signs before the client walks. C: Measure the client's vital signs before the client walks. D: Offer to assist the client to void prior to walking in the hall. E: Report the onset of any dizziness or lightheadedness. A client is in contact isolation due to a stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client's room. In which order should the nurse perform the interventions? A: Change coccyx dressing, perform tracheostomy care, restart the IV. B: Perform tracheostomy care, change coccyx dressing, restart the IV. C: Restart the IV, perform tracheostomy care, change coccyx dressing. D: Change coccyx dressing, restart the IV, perform tracheostomy care. C: Restart the IV, perform tracheostomy care, change coccyx dressing. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is most important for the nurse to implement? A: Determine what home remedies were used. B: Assess for the presence of an impaction. C: Obtain list of prescribed home medications. D: Evaluate stool sample for presence of blood. A: Determine what home remedies were used. What information is most important for the nurse to obtain in determining a client's need for referral for obesity counseling? A: Body weight 10% over ideal weight. B: Body mass index greater than 35. C: Daily caloric intake of 3500 calories. D: Client's expressed desire to lose 50 pounds. B: Body mass index greater than 35. A client on a prescribed full liquid diet has a nursing diagnosis of "Risk for impaired skin integrity related to reduced oral intake." What snack is best to provide this client? A: Beef broth or chicken broth. B: Purified lowfat milk. C: Apple or grapefruit juice. D: Ensure, a liquid supplement. D: Ensure, a liquid supplement. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saved in the container. What interventions should the nurse initiate? A: Discard the urine and start another 24 hour period. B: Notify the charge nurse of the problem. C: Notify the healthcare provider of the situation. D: Add another hour to the urine collection period. A: Discard the urine and start another 24 hour period. A confused elderly male client is having trouble sleeping at night and is sometimes found wondering in the hallway. What nursing intervention should the nurse implement first? A: Apply wrist restraints to prevent wandering. B: Provide a back rub at bedtime. C: Leave the door to his room open slightly. D: Administer a PRN sedative prescription. B: Provide a back rub at bedtime. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what question should the nurse ask this client? A: "How frequently do you eat processed or canned foods?" B: "Do you drink milk or eat dairy products at each meal?" C: "How much water and ice chips do you have each day?" D: "What amount of your daily meals contains fresh vegetables?" C: "How much water and ice chips do you have each day?" A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? A: Encourage the client to use guided imagery and slow, rhythmic breathing. B: Provide 20 minutes of back massage. C: Encourage the client to watch TV. D: Place a hot water circulation device, such as an Aqua K pad. A: Encourage the client to use guided imagery and slow, rhythmic breathing. Which assessment finding is most significant in determining the level of assistance a client requires with personal care? A: 2+ pitting edema in the lower extremities. B: Disorientation to person, place, and time. C: A red rash in the groin area. D: Firm abdomen with hypoactive bowel sounds. B: Disorientation to person, place, and time. 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. B. Take medication Q12H as prescribed IM ventrogluteal landmark A. Upper outer quadrant of buttock B. Deltoid C. Knee and greater trochanter D. Greater trochanter and anterior superior iliac spine D. Greater trochanter and anterior superior iliac spine 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 D. Offer to warm up the prune juice 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 D. Determine client's activity tolerance 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 D. Expand abdomen during inspiration and let the abdomen sink during exhalation Highest priority? A. Impaired bed mobility B. Fluid volume deficit C. Bowel incontinence D. Caregiver role strain B. Fluid volume deficit 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 D. Notify IT A Native American client complains of abdominal cramping and nausea. What is the most important factor to assess? A. Family decision-making regarding health B. Recent use of home remedies and herbs C. Employment status B. Recent use of home remedies and herbs A nurse is educating a client on 24-hour urine test. The client states that the first void is in the urinal. A. Add the urine from the urinal to the collection container B. Start collecting with next void C. Start collecting the next day D. Check urine for sediments B. Start collecting with next void 25. A Muslim female comes to the clinic for an initial assessment A. Obtain most of her history from her family members B. Determine what the client consider to be her ethnicity B. Determine what the client consider to be her ethnicity 29. What should the nurse implement when inserting an indwelling catheter to an uncircumcised male. A. Clean meatus before retracting the foreskin B. Advance catheter before inflating balloon C. Sterile field should be even between nurse's hips D. Wipe the meatus back and forth B. Advance catheter before inflating balloon A nurse notices a fire in the bathroom of an empty room and reports the location of the fire immediately. What should the nurse do next? A. Close the door to all the client's rooms in the hallway B. Evacuate clients in the rooms close to the fire C. Shut the door to the bathroom and the empty room D. Obtain fire extinguisher on the unit C. Shut the door to the bathroom and the empty room 32. Proper method of wound care A. Cleaning outwards to inward B. Cleaning inward to outward C. Cleaning back and forth D. Wiping sterile cotton swab twice B. Cleaning inward to outward A nurse walks into a client's room to see him coughing non-productively into his upper sleeve. The nurse should: A. Obtain face masks for all staff entering client's room B. Teach client how to cough into his hands C. Provide tissues for the client to cough into C. Provide tissues for the client to cough into A confused elderly patient is having trouble sleeping and is often found wandering the halls. The nurse should: A. Administer PRN sedative B. Have client's room door open slightly C. Provide back rub before bed D. Apply soft wrist restraints to prevent wandering C. Provide back rub before bed A mother requests to see her 18 year-old lab results. What is the nurse's best response? A. I will give you the results when it is back. B. I can only give the results to your son. He is an adult. C. The healthcare provider will give you the results. B. I can only give the results to your son. He is an adult. What should the nurse do when interviewing a client about sexual and reproductive matters? Less sensitive first A client is on a full liquid diet for "Volume deficit related to less than required oral intake." What should the nurse give to the client? A. Beef or chicken broth B. Ensure C. Low-fat milk D. Apple or grapefruit juice B. Ensure A post-op client has concerns with using his bedpan. He is prescribed activity from bed to chair at least 3 times a day. Encourage client to use bedside commode A nurse is providing passive ROM pronation and supination on an adolescent. What should the nurse do next? [Picture of adolescent hand on nurse's hand in pronation). Turn hand so palm faces up Hospice SATA A. Provides comfort and dignity B. Can be at home C. Living will not active in hospice A B D E It is most important for a nurse to recalculate a patient's Braden score who develops which problem? A: Urinary incontinence. B: Hypoactive bowel sounds. C: Weakened cough reflex. D: 2+ pitting edema to both legs. A: Urinary incontinence. Which statement is an example of a correctly written nursing diagnosis? A: Altered tissue perfusion R/T congestive heart failure. B: Altered urinary elimination R/T urinary tract infection. C: Risk for impaired tissue integrity R/T client's refusal to turn. D: Ineffective coping R/T response to positive biopsy test results. D: Ineffective coping R/T response to positive biopsy test results. The nurse is providing passive ROM exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? A: Raise the bed to a comfortable working level. B: Bend the client's knee. C: Move the knee toward the chest as far as it will go. D: Cradle the client's heel. D: Cradle the client's heel. What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? A: Maintain in a lateral position using protective wrist and vest devices. B: Position prone with a small pillow below the diaphragm. C: Raise the head and knee gatch when lying in a supine position. D: Transfer into a wheelchair close to the nurses's station for observation. B: Position prone with a small pillow below the diaphragm. The nurse is administering an intermittent infusion of an antibiotic to a client whose IV access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? A: Check for a blood return. B: Reposition the client's arm. C: Remove the IV site dressing. D: Flush the lock with saline. B: Reposition the client's arm. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? A: Hydrogel. B: Exudate absorber. C: Wet to moist dressing. D: Transparent adhesive film. C: Wet to moist dressing. When caring for an immobile client, what nursing diagnosis has the highest priority? A: Risk for fluid volume deficit. B: Impaired gas exchange. C: Risk for impaired skin integrity. D: Altered tissue perfusion. B: Impaired A 35 year old female client refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment. The patient states she is ready to go home and die. What intervention should the nurse initiate? A: Review the medical record for an advanced directive. B: Determine if the physician has written a DNR. C: Document that the client is being discharged against medical advice. D: Determine if the client is competent to refuse medical treatment. D: Determine if the client is competent to refuse medical treatment. The nurse assess an elderly, immobilized male patient, BP: 138/7, Temp: 96.9, urine output=100ml concentrated urine in the last hour. He has increased respiratory secretions and wet lung sounds. Which nursing action is the most important to implement? A: Administer a PRN antihypertensive medication. B: Provide the patient with an extra blanket. C: Encourage increased fluid intake. D: Turn every 2 hours. D: Turn every 2 hours.