HESI Fundamentals Exam Practice Questions (graded A+)

HESI Fundamentals Exam Practice Questions (graded A+) A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A.) Accused of diversion. B.) Reported for stealing. C.) Reported for a HIPAA violation. D.) Accused of unprofessional conduct. - A Rationale: Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A.) Use distraction techniques during times of spiritual stress and crisis. 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. - D Rationale: The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A.) Stage 1 pressure sore draining sero-sanguineous drainage. 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. - C Rationale: Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A.) Portable syringe pump. B.) Cassette infusion pump. C.) Volumetric controller. D.) Nonvolumetric controller. - B Rationale: A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size. How should the nurse handle linens that are soiled