HESI Fundamentals Exam
a 35 year old female client with cancer refuses to allow the nurse to insert an IV for a scheduled
chemotherapy treatment, and states that she is ready to go home and die. What intervention
should the nurse initiate?
A. evaluate the client's mental status for competence to refuse treatment
B. review the client's medical record for an advance directive
C. determine if a DNR prescription has been obtained
D. document that the client is being discharged against medical advice - ANSA. evaluate the
client's mental status for competence to refuse treatment
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical
procedure. Which laboratory test indicated the client's protein status for the longest length of
time.
A. Urine urea
B. transferrin
C. prealbumin
D. serum albumin - ANSD. serum albumin
What client statement indicates to the nurse that the client requires assistance with bathing?
A. "I only bathe every other day"
B. "I left my eyeglasses at home"
C. "I don't understand why I'm so weak and tired"
D. "I wasn't able to pack a bag before I left for the hospital" - ANSC. "I don't understand why I'm
so weak and tired"
How should a nurse handle linens that are soiled with incontinent feces?
A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper
B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper
C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room
D. place an isolation hamper in the client's room and discard the linens in it - ANSD. place an
isolation hamper in the client's room and discard the linens in it
When caring for an immobile client, what nursing diagnosis has the highest priority?
A. altered tissue perfusion
B. impaired gas exchange
C. risk for fluid volume deficit
D. risk for impaired skin integrity - ANSB. impaired gas exchange
The nurse assess an immobile, elderly male client and determines that his blood pressure is
138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the last
, hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these
assessment findings, what nursing action is the most important for the nurse to implement?
A. encourage additional additional fluid intake
B. provide the client with an additional blanket
C. turn the patient Q2
D. administer a PRN anti hypertensive prescription - ANSC. turn the patient Q2
The home health nurse visits an elderly female client who had a brain attack three months ago
and is now able to ambulate with the assistance of a quad cane. Which assessment finding has
the greatest implications for this client's case?
A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago
B. the client tells the nurse that she does not have much of an appetite today
C. the husband, who is the caregiver, begins to weep when you ask how he is doing
D. the nurse notes that there are numerous scatter rubs throughout the house - ANSD. the
nurse notes that there are numerous scatter rubs throughout the house
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-anguineous drainage
B. one-inch pressure sore draining serous fluid
C. pressure sore draining serous fluid
D. pressure sore on heel with a small amount of purulent drainage - ANSB. one-inch pressure
sore draining serous fluid
A medication is prescribed to be given QID. What schedule should the nurse use to administer
this prescription?
A. 800
B. 0800, 1200, 1600, 2000
C. every other day at 0800
D. 0800, 1200, 1600, 2000, 0000, 0400 - ANSB. 0800, 1200, 1600, 2000
The nurse working in the emergency department is assessing four client's ability to tolerate pain.
Which client is likely to tolerate a higher level of pain.
A. A 23-year-old woman who sprained her knee while biking
B. a 55-year-old woman who has had moderate low back pain for three months
C. A 10-year-old who was burned by a camp fire earlier today
D. A 70 year-old who has a postoperative infection from a surgery one week ago - ANSB. a
55-year-old woman who has had moderate low back pain for three months
A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, " will
it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to
provide?
a. "It won't hurt because you're such a big boy"
a 35 year old female client with cancer refuses to allow the nurse to insert an IV for a scheduled
chemotherapy treatment, and states that she is ready to go home and die. What intervention
should the nurse initiate?
A. evaluate the client's mental status for competence to refuse treatment
B. review the client's medical record for an advance directive
C. determine if a DNR prescription has been obtained
D. document that the client is being discharged against medical advice - ANSA. evaluate the
client's mental status for competence to refuse treatment
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical
procedure. Which laboratory test indicated the client's protein status for the longest length of
time.
A. Urine urea
B. transferrin
C. prealbumin
D. serum albumin - ANSD. serum albumin
What client statement indicates to the nurse that the client requires assistance with bathing?
A. "I only bathe every other day"
B. "I left my eyeglasses at home"
C. "I don't understand why I'm so weak and tired"
D. "I wasn't able to pack a bag before I left for the hospital" - ANSC. "I don't understand why I'm
so weak and tired"
How should a nurse handle linens that are soiled with incontinent feces?
A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper
B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper
C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room
D. place an isolation hamper in the client's room and discard the linens in it - ANSD. place an
isolation hamper in the client's room and discard the linens in it
When caring for an immobile client, what nursing diagnosis has the highest priority?
A. altered tissue perfusion
B. impaired gas exchange
C. risk for fluid volume deficit
D. risk for impaired skin integrity - ANSB. impaired gas exchange
The nurse assess an immobile, elderly male client and determines that his blood pressure is
138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the last
, hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these
assessment findings, what nursing action is the most important for the nurse to implement?
A. encourage additional additional fluid intake
B. provide the client with an additional blanket
C. turn the patient Q2
D. administer a PRN anti hypertensive prescription - ANSC. turn the patient Q2
The home health nurse visits an elderly female client who had a brain attack three months ago
and is now able to ambulate with the assistance of a quad cane. Which assessment finding has
the greatest implications for this client's case?
A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago
B. the client tells the nurse that she does not have much of an appetite today
C. the husband, who is the caregiver, begins to weep when you ask how he is doing
D. the nurse notes that there are numerous scatter rubs throughout the house - ANSD. the
nurse notes that there are numerous scatter rubs throughout the house
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-anguineous drainage
B. one-inch pressure sore draining serous fluid
C. pressure sore draining serous fluid
D. pressure sore on heel with a small amount of purulent drainage - ANSB. one-inch pressure
sore draining serous fluid
A medication is prescribed to be given QID. What schedule should the nurse use to administer
this prescription?
A. 800
B. 0800, 1200, 1600, 2000
C. every other day at 0800
D. 0800, 1200, 1600, 2000, 0000, 0400 - ANSB. 0800, 1200, 1600, 2000
The nurse working in the emergency department is assessing four client's ability to tolerate pain.
Which client is likely to tolerate a higher level of pain.
A. A 23-year-old woman who sprained her knee while biking
B. a 55-year-old woman who has had moderate low back pain for three months
C. A 10-year-old who was burned by a camp fire earlier today
D. A 70 year-old who has a postoperative infection from a surgery one week ago - ANSB. a
55-year-old woman who has had moderate low back pain for three months
A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, " will
it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to
provide?
a. "It won't hurt because you're such a big boy"
