HESI Fundamentals Questions and Answers Scored A+ 2023

HESI Fundamentals Questions and Answers Scored A+ 2023 During a routine assessment, an obese 50-year-old client states, "I feel so unlovable because of my weight." Which is the best response by the nurse? A. Reassure the client that many obese people have concerns about sex. B. Remind the client that sexual relationships need not be affected by obesity. C. Determine the frequency of sexual intercourse. D. Ask the client to talk about specific concerns. Option D provides an opportunity for the client to verbalize concerns and provides the nurse with more assessment data. Options A and B may not be related to the current concern, assume that obesity is the problem, and are communication blocks. Option C may be appropriate after discussing the stated concerns. In assisting an older adult client prepare to take a tub bath, which nursing action is most important? A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels. To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety. A nurse is working in an occupational health clinic when an employee walks in and states, "I was walking outside and I believe I was just struck by lightning." The client is alert but reports feeling faint. Which assessment will the nurse perform first? A. Pulse characteristics B. Open airway C. Entrance and exit wounds D. Cervical spine injury Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the pulse rate and regularity is a priority. Because the client is talking, he has an open airway so that assessment is not necessary. Assessing for options C and D should occur after assessing for adequate circulation. The nurse is evaluating the chart of a client scheduled for surgery in 1 hour. When viewing the consent form, the nurse notes the surgeon’s signature, but not the client’s signature. What steps must the nurse take? (Select all that apply.) A. Call the surgeon. B. Ask the client, “Did your surgeon explain the procedure to you?” C. Have the client’s spouse sign the form. D. Ask the client, “Do you have any questions?” E. Witness the signature. F. Obtain the consent. Correct Answer: B,D,E It is the surgeon’s responsibility to review the procedure with the client until the client has no further questions. The nurse can verify the review by the surgeon and ask if the client has any further questions. If the client has questions, the nurse must call in the surgeon. When the nurse signs the consent form, the nurse is witnessing the signature only. The nurse is preparing to initiate parenteral nutrition (PN) for a client. What actions will the nurse consider when administering PN? (Select all that apply.) A. Remove the PN from the refrigerator 30 minutes before infusing. B. Have a second nurse double check the PN before connecting the solution. C. Have a second IV line in place for administering IV medications. D. Assure the infusion time for the PN does not exceed 24 hours. E. Tell the client a feeling of being full should occur with PN. F. Return amber and cloudy solutions of PN to the pharmacy. Correct Answer: A,D,F Rationale:There are no issues with antibody incompatibility with PN, so there is no need to double check the PN, or start a second IV line. PN is administered through the venous system and does not satiate the client. The remaining selections are true about the administration of PN. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, what is the priority nursing action? A. Encourage the client to increase ambulation in the room. B. Offer the client a high-carbohydrate snack for energy. C. Force fluids to thin the client's pulmonary secretions. D. Determine if pain is causing the client's tachypnea. Correct Answer: D Rationale:Pain, anxiety, and increasing fluid accumulation in the lungs can cause tachypnea (increased respiratory rate). Encouraging the client to increase ambulation when the respiratory rate is rising above normal limits puts the client at risk for further oxygen desaturation. Option B can increase the client’s carbon metabolism, so an alternative source of energy, such as Pulmocare liquid supplement, should be offered instead. Option C could increase respiratory congestion in a client with a poorly functioning cardiopulmonary system, placing the client at risk of fluid overload. When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety? A. Securely grasp the client's arm and leg. B. Put bed rails up on the side of bed opposite from the nurse. C. Correctly position and use a turn sheet. D. Lower the head of the client's bed slowly. Incorrect | Correct Answer: B Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails. The nurse manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which action should be included in this instruction? A. Perform range-of-motion exercises to prevent contractures. B. Decrease the client's fluid intake to prevent diarrhea. C. Massage the client's legs to reduce embolism occurrence. D. Turn the client from side to back every shift. Correct: A Performing range-of-motion exercises is beneficial in reducing contractures around joints. Options B, C, and D are all potentially harmful practices that place the immobile client at risk of complications. A client in a long-term care facility reports to the nurse, "I have not had a bowel movement in 2 days." What is the nurse's first action? . Instruct the caregiver to offer a glass of warm prune juice at mealtimes. B. Notify the health care provider and request a prescription for a large-volume enema. C. Assess the client's medical record to determine the client's normal bowel pattern. D. Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day. Correct Answer: C Rationale:This client may not routinely have a daily bowel movement, so the nurse should first assess this client’s normal bowel habits before attempting any intervention. Options A, B, or D may then be implemented, if warranted. A client with frequent urinary tract infections (UTIs) asks the nurse to explain a friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide? Correct Answer: C Rationale:Cranberry juice maintains urinary tract health by reducing the adherence of Escherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown to be as effective as cranberry juice in preventing UTIs. A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A. Notify the friend that all medical information will be kept confidential. B. Explain the relationship to the charge nurse and ask for reassignment. C. Approach the client and ask if the assignment is uncomfortable. D. Accept the assignment but protect the client's confidentiality. Correct Answer: B Rationale:Caring for a close friend can violate boundaries for nurses and should be avoided when possible (B). If the assignment is unavoidable (there are no other nurses to care for the client) then C, A, and D should be addressed. The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take? A. Consult with the pharmacist about the need to continue the medication. B. Administer the antihypertensive medication as prescribed preoperatively. C. Withhold the medication until the client is fully alert and vital signs are stable. D. Contact the health care provider to renew the prescription for the medication. Correct Answer: D Rationale:Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact the health care provider if the antihypertensive medication is not included in the postoperative prescriptions. The pharmacist does not prescribe medications or renew prescriptions. The nurse must have a current prescription before administering any medications. A terminally ill client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide? A. Administer the prescribed maximum dose of pain medication. B. Talk with the client about thoughts and feelings about death. C. Collaborate with the health care provider about initiating antidepressant therapy. D. Refer the client to the ethics committee of her local health care facility. Correct Answer: B Rationale:The nurse should first assess the client’s feelings about death and determine the extent to which this statement expresses the client’s true feelings. The client may need additional pain management, but further assessment is needed before implementing option A. Options C and D are both premature interventions and should not be implemented until further assessment is obtained. The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access? A. Left brachial vein B. Right cephalic vein C. Dorsal side of the right wrist D. Right upper extremity Correct Answer: B The cephalic vein is large and superficial and identifies the anatomic name of the vein that is accessed, which should be included in the documentation. The basilic vein of the arm is used for IV access, not the brachial vein, which is too deep to be accessed for IV infusion. Although veins on the dorsal side of the right wrist are visible, they are fragile and using them would be painful, so they are not recommended for IV access. Option D is not specific enough for documenting the location of the IV access. The nurse notes in the client’s plan of care altered sleep patterns related to nocturia. Which nursing actions are important for the nurse to provide? (Select all that apply.) A. Decrease intake of fluids after the evening meal. B. Drink a glass of cranberry juice every day. C. Drink a glass of warm decaffeinated beverage at bedtime. D. Consult the health care provider about a sleeping pill. E. Assess the client’s usual sleep pattern. Correct Answer: A,E Nocturia is urination during the night. Option A is helpful to decrease the production of urine, thus decreasing the need to void at night. Option E gives the nurse the client’s baseline sleep pattern. Option B helps prevent bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result in urinary incontinence if the client is sedated and does not awaken to void. The nurse is making an initial daily assessment at 0715 and notes 550 mL of LR running at 75 mL an hour. At what time, in military time, will the nurse hang the next bag of IV fluid? _____ Correct Answer: 1435 60 min × 0.33333 = 19.99 min = 20 min 7 hr 20 min + 0715 = 1435 The nurse is preparing the room for a client after a laparotomy with a 5 inch midline abdominal incision. The nurse plans on teaching the client how to splint the wound when coughing or deep breathing. What extra item will the nurse place in the client's room? A. Pillow case B. Pillow C. Sheet D. Blue absorbent pad Correct Answer: B The purpose of splinting an incision is to offer additional support to the wound. The client can hold a pillow or rolled up blanket against the abdominal incision. The remaining items do not offer the level of support necessary to splint the wound. A 65-year-old client who attends an adult daycare program and is wheelchair mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? . "Take a vitamin supplement tablet once a day." B. "Change positions in the chair frequently" C. "Increase daily intake of water or other oral fluids." D. "Purchase a newer model wheelchair." Correct Answer: B Rationale:The most important teaching is to change positions frequently because pressure is the most significant factor related to the development of pressure ulcers. Increased vitamin and fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an intervention of last resort because this will be very expensive for the client. The nurse is providing care to a client receiving sq heparin every 12 hours at 8:00 am and 8:00 pm. The healthcare provider prescribes an aPTT test. At what time will the nurse plan on drawing the test? A. 7:00 am B. 9:00 am C. 12:00 noon D. 2:00 pm Correct Answer: A Rationale:The aPTT test should be drawn 1 hour before the scheduled dose.