HESI Fundamentals Practice Exam

HESI Fundamentals Practice Exam A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that she's ready to go home to die. What intervention should the nurse initiate? - ANS Evaluate the client's mental status for competence to refuse treatment Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not necessary for competent client to refuse care. A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates client's protein status for the longest length of time? - ANS Serum albumin Rationale: Serum albumin has a long half-life. What client statement indicates to the nurse that the client requires assistance with bathing? - ANS "I don't understand why I'm so weak & tired." How should the nurse handle linens that are soiled with incontinent feces? - ANS Place the soiled linens in a pillow case & deposit them in the dirty linen hamper When caring for an immobile client, what nursing diagnosis has the highest priority? - ANS Impaired gas exchange The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing action is most important for the nurse to implement? - ANS Turn the client q2h Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring. The home health nurse visits an elderly female client who had a brain attack 3 months ago & is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care? - ANS The nurse notes there are numerous scatter rugs throughout the house The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter & 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? - ANS One-inch pressure sore draining serous fluid Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx? - ANS 0800, 1200, 1600, 2000 The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to tolerate a higher level of pain? - ANS 1 55y/o woman who has had moderate low back pain for 3 months Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to relieve the pain. All other clients are having new experiences with pain. A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt to have my tonsils & adenoids taken out?" Which response is best for the nurse to provide? - ANS "It may hurt, but we'll give you medicine to help you feel better." A low-sodium, low-protein diet is prescribed for a 45y/o client with renal insufficiency & HTN, who gained 3lbs in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24hr diet recall? - ANS 1. Snack of potato chips & diet soda 2. Lunch of tuna, carrots, fruit & coffee 3. Breakfast of eggs, bacon, toast & coffee 4. Bedtime snack of crackers & milk What intervention should the nurse include in the care plan for a client who is being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency? - ANS Check capillary refill of toes on lower extremity with Unna's paste boot Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation. No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly removal is reasonable. Male client with nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for this client? - ANS Use reflective listening techniques when the client expresses spiritual doubts. Rationale: Client should be consulted before involving chaplain. Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to impending death." What intervention is best for the nurse to implement when caring for this client? - ANS Assist & support the client in establishing short-term goals. Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to death. Nurse who puts meds in her uniform pocket to deliver to clients confides that after arriving home, she found a hydrocodone tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? - ANS Accused of diversion A signed consent form indicated a client should have an electromyogram, by a myelogram was performed instead. Thought the myelogram revealed the cause of the client's back pain, the client filed a lawsuit against the nurse & HCP for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent which infraction? - ANS Assault & battery with deliberate intent to deviate from the consent form A 75y/o client who has a history of end stage renal failure & advancing lung cancer, recently had a stroke. 2 days ago, the HCP d/c the client's dialysis treatments, stating that death is inevitable, but the client is disoriented & will not sign a DNR directive. What is the priority nursing intervention? - ANS Determine who is legally empowered to make decisions The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? - ANS Refuse to perform the task that is beyond the nurse's experience Rationale: According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency. Before administering a client's medication, the nurse assesses a change in the client's condition & withholds the medication until consulting with the HCP. The dose is changed & the nurse administers the new Rx 1 hour later than originally scheduled. What action should the nurse implement in response to this situation? - ANS Document the events that occurred in the nurses' notes. On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? - ANS Provide warm prune juice before the client goes to bed at night The home health nurse visits an elderly client who lives at home with her husband. She experiences frequent episodes of diarrhea & bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? - ANS Fluid volume imbalance A nurse observes a student nurse taking a copy of a client's medication administration record. What response should the nurse provide first? - ANS Explain that the records are hospital property & may not be removed. After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? - ANS Notify the surgeon that the consent form has not been signed Rationale: Once a client has been premedicated for surgery with any type of sedative, legal informed consent is not possible, so the nurse must notify the surgeon. Remaining options are not legally viable options for ensuring informed consent. A client who has been on bedrest for several days now has a prescription to progress daily activity as tolerated. When nurse assists client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? - ANS Advise the client to sit on the side of the bed for a few minutes before standing again. The charge nurse observes a UAP bending at the waist to lift a 20lb box. What instruction should the charge nurse provide? - ANS Bend at the knees when lifting heavy objects AN older client with RA is complaining of severe joint pain that is caused by weight of the linen on her legs. What action should the nurse implement first? - ANS Drape the sheets over the footboard of the bed A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the UAP who is assisting with a bed bath? - ANS Take measures to promote as much comfort as possible A client arrives for scheduled needle aspiration. He tells the nurse he has already given verbal consent to the HCP. What action should the nurse implement? - ANS Witness the client's signature on the consent form In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation when the client is in supine position. What action should the nurse implement? - ANS Document the presence & volume of the pulse palpated A nurse is preparing to insert a rectal suppository & observes a small amount of rectal bleeding. What action should the nurse implement? - ANS Withhold the administration of the suppository until contacting the HCP The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? - ANS Draw up the irrigating solution into the syringe. Rationale: First apply gloves, then draw up the irrigating solution. Syringe is attached to catheter & fluid is instilled, using aseptic technique. Once instilled, catheter should be secured to drainage tubing. Drainage bag can be emptied whenever I&O measurement is indicated When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse. - ANS The clamp on the urinary drainage bag is open While preparing to insert a rectal suppository into a male adult client, the nurse observes the client holding his breath while bearing down. What action should the nurse implement? - ANS Instruct the client to take slow deep breaths & stop bearing down The nurse is completing the care plan for a client who is admitted for BPH. Which data should the nurse document as a subjective finding? - ANS Complains of inability to empty bladder While the nurse is administering a bolus feeding to a client via NG tube, the client begins to vomit. What action should the nurse implement first? - ANS D/c administration of the bolus feeding What is the rationale in using the nursing process in planning care for clients? - ANS As a tool to organize thinking & clinical decision making about clients' healthcare needs What activity should the nurse use in the evaluation phase of the nursing process? - ANS Examine the effectiveness of nursing interventions toward meeting client outcomes Which statement is an example of a correctly written nursing diagnosis statement? - ANS Ineffective coping related to response to positive biopsy test results Rationale: "Diagnostic label" followed by "related to" the cause, which should direct the nurse to the appropriate interventions. Should not include medical diagnosis. Should not focus on client's response. What action by the nurse demonstrates culturally sensitive care? - ANS Asks permission before touching a client A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? - ANS Examine one's own culturally based values, beliefs, attitudes & practices. Rationale: Cultural sensitivity begins with examining one's own cultural values. Which technique is most important for a nurse to implement when performing a physical assessment? - ANS Consistent, systematic approach A 73y/o Hispanic client is seen with a history of protein malnutrition. What information should the nurse obtain first? - ANS Foods & liquids consumed during past 24 hrs Rationale: Client's dietary habits should be determined first through dietary recall before suggesting protein sources or supplements as options in client's diet. Nurse formulates nursing diagnosis of "ineffective health maintenance related to lack of motivation" for a client with DM2. Which finding supports this nursing diagnosis? - ANS Eats anything & does not think diet makes a difference in health Rationale: Diagnosis is best exemplified in client belief or understanding about diet & health maintenance. Which statement correctly identifies a written learning objective for a client with PVD? - ANS Upon discharge, the client will list 3 ways to protect feet from injury Middle-aged woman enjoys being a teacher & mentor. Feels that she should pass down her legacy of knowledge & skills to the younger generation. According to Erikson, she is involved in what developmental stage? - ANS Generativity Which statement best describes durable POA for healthcare? - ANS Client signs a document that designates another person to make legally binding healthcare decisions if the client is unable to do so Client with an infected wound tells nurse he follows a macrobiotic diet. What foods should the nurse recommend? - ANS Combination of plant proteins to provide essential amino acids Client with Raynaud's disease asks the nurse about using biofeedback for self-management of symptoms. What response is best for the nurse to provide? - ANS Biofeedback allows the client to control involuntary responses to promote peripheral vasodilation Client informs the nurse that she uses herbal therapies. What information should the nurse offer about general use of herbal supplements? - ANS Herbs should be obtained from manufacturers with history of quality control of their supplements Client who has breast cancer with metastasis to the liver & spine is admitted with constant, severe pain despite around-the-clock use of oxycodone & amitriptyline for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? - ANS Sensory pattern, area, intensity & nature of pain Client who has moderate, persistent, chronic neuropathic pain d/t diabetic neuropathy takes gabapentin & ibuprofen daily. If Step 2 of the WHO pain relief ladder is prescribed, which drug protocol should be implemented? - ANS Continue gabapentin To obtain the most complete assessment for a client with chronic pain, which information should the nurse obtain? - ANS Which activities during a routine day are impacted by your pain? Male client with AIDS develops cryptococcal meningitis & tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement? - ANS Ask the client if his decision has been discussed with his HCP. Male client with venous incompetence stands up and his BP subsequently drops. Which finding should the nurse identify as a compensatory response? - ANS Increase in pulse rate Daughter of an older woman who became depressed following the death of her husband asks, "My mother was always well-adjusted until my father died. Will she tend to be sick from now on?" Which response is best for the nurse to provide? - ANS "It's highly likely that she will recover & return to her pre-illness state." Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? - ANS Emptying the urinary catheter drainage bag for a client with Alzheimer's disease What action should the nurse implement when adding sterile liquids to a sterile field? - ANS Consider the sterile field contaminated if it becomes wet during the procedure HCP is performing a sterile procedure at client's bedside. Nurse observes HCP break sterility. What is the best action for the nurse to implement? - ANS Identify the break in surgical asepsis & provide another set of sterile supplies Older client who is able to stand but not ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? - ANS Place a transfer belt around the client, assist to stand & pivot to a chair that is placed at a right angle to bed What action should the nurse implement to prevent the formation of a sacral ulcer for a client who is immobile? - ANS Position prone with a small pillow below the diaphragm What is most important for the nurse to implement when placing a client in the Sim's position? - ANS Raise the bed to a wasit-high working level Nurse is providing passive ROM exercises to hip & knee for unconscious client. After supporting the client's knee with one hand, what action should the nurse take? - ANS Cradle the client's heel The nurse is caring for a client who is weak from inactivity because of a 2-week hospitalization. In planning care for the client, the nurse should include which ROM exercises? - ANS Active ROM exercises to both arms & legs 2-3 times daily The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure & take corrective action if which client reaction is noted? - ANS Pulse rate decreases from 78 to 52 beats/min A client provides the nurse with information about the reason for seeking care. Nurse realizes some info about past hospitalizations is missing. How should the nurse obtain this information? - ANS Elicit specific fats about past hospitalizations with direct questions The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which supplement should nurse encourage client to include in dietary plan? - ANS Vitamin B12 A client is admitted with a stage 4 pressure ulcer that has a black, hardened surface & a light pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first? - ANS Wet to moist While caring for a child & mother from Cambodia, which action should the nurse implement to accommodate the clients' cultural needs? - ANS Speak initially with the oldest family member to show respect The nurse is preparing to give a client with dehydration IV fluids delivered at a continuous rate of 175 mL/hr. Which infusion device should the nurse use? - ANS Cassette infusion pump The nurse overhears the HCP explaining to the client that the tumor removed was non-malignant & that the client will be fine. Nurse has read in the pathology report that the tumor was malignant & that there is extensive metastasis. Who should the nurse consult with first regarding the situation? - ANS HCP Single mom was just told she has advanced cancer. She expresses concern about who will care for her children. Which statement made by the nurse is likely to be most helpful at this time? - ANS "Tell me what you would like to see happen with your children in the future" Rationale: Nurse should first assess what the client desires. Terminally ill patient in LTC exhibits signs of impending death & has a DNR status. What intervention should the nurse implement first? - ANS Notify family members of the client's condition Nurse is preparing patient with catheter & IV infusion to ambulate from bed to chair for first time following abdominal surgery. What action(s) should nurse implement prior to assisting client to the chair? - ANS 1. Premedicate with an analgesic 2. Inform client of plan for moving to the chair 3. Ask client to push IV pole to the chair 4. Assess the client's BP When the nurse enters client's room, client shouts, "Get out of my room! I'm tired of being bothered!" How should nurse respond? - ANS "What is concerning you this morning?" Rationale: open-ended question that encourages client to discuss personal feelings Nurse encounters slight resistance when inserting tubing into a client's rectum for a tap water enema. What action should the nurse implement? - ANS Ask the client to relax & twist the tube gently through the sphincter Client demonstrates positive Chvostek's sign. What action should the nurse take? - ANS Ask the client about numbness or tingling in the hands When preparing to administer IV med through central venous catheter, nurse aspirated blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? - ANS Flush the lumen with the saline solution & administer the medication through the lumen Which client assessment data is most important for the nurse to consider before ambulating post-op client? - ANS Respiratory rate Rationale: mobilization & ambulation increase oxygen use Nurse is administering intermittent infusion of abx to a client whose IV access is an AC saline lock. After nurse opens roller clamp on the IV tubing, the alarm on the pump indicates an obstruction. What actions should the nurse take first? - ANS Reposition the client's arm Which nursing intervention is most beneficial in reducing risk of urosepsis in a hospitalized client with an indwelling urinary catheter? - ANS Obtain prescription for removal of catheter ASAP In evaluating client care, which action should the nurse take first? - ANS Determine if expected outcomes of care were achieved When assessing client with nursing dx of fluid volume deficit, the nurse notes that the client's skin over sternum "tents" when gently pinched. Which action should the nurse implement? - ANS Continue the planned nursing interventions to restore the client's fluid volume Prior to administering newly prescribed medication, nurse reviews adverse effects & determines priority risks to the client. While performing this action, nurse is engaged in which step of the nursing process? - ANS Analysis When teaching female client to perform intermittent self-catheterization, the nurse should ensure client's ability to perform which action? - ANS Locate the perineum Nurse determines client's IV solution is infusing at 250 mL/hr. Prescribed rate is 125 mL/hr. What action should the nurse take first? - ANS Slow the IV infusion to keep vein open (KVO) rate Rationale: Should change flow rate to KVO to prevent further risk of fluid volume overload, then gather additional assessment data, such as when the IV solution was started & appearance of IV site before contacting HCP Male nurse is assigned to care for female Muslim client. When nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? - ANS "I will ask one of the female nurses to bathe you." As the nurse prepares the equipment to be used to start an IV on a 4y/o boy in the treatment room, he cries continuously. What intervention should the nurse implement? - ANS Ask the mother to be present to soothe the child Client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has highest priority? - ANS Inform the family that death is imminent Nurse notes that client consistently coughs when eating & drinking. Which nursing diagnosis is most important for the nurse to include in patient's care plan? - ANS Risk for aspiration When making bed of a client who needs a bed cradle, which action should the nurse include? - ANS Drape the top sheet & covers loosely over the bed cradle Rationale: Bed cradle is used to keep top bed linens off of the client.