HESI FUNDAMENTALS PRACTICE TEST HESI NURSING
FUNDAMENTALS QUESTIONS AND CORRECT DETAILED ANSWERS
ALREADY GRADED A+ 100%
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The nurse
determines that the client has been noncompliant with the diet, based on which report
from the 24-hour dietary recall? (Select all that apply.)
A. Snack of potato chips, and diet soda.
B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C. Breakfast of eggs, bacon, toast, and coffee.
D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E. Bedtime snack of crackers and milk. - ANSWER>>>Potato chips (A) are high in
sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only
(D) is a meal that is in compliance with a low sodium, low protein diet.
Correct ANSWER: A, B, C, E
.What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing. - ANSWER>>>The
Unna's paste boot becomes rigid after it dries, so it is important to check distally for
adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an
ace bandage may be used to cover both, but no bandage should be put under it (B).
The Unna's paste boot should be applied from the foot and wrapped towards the knee
(C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h.
Weekly removal is reasonable (D).
Correct ANSWER: A
,.A 75-year-old client who has a history of end stage renal failure and advanced lung
cancer, recently had a stroke. Two days ago the healthcare provider discontinued the
client's dialysis treatments, stating that death is inevitable, but the client is disoriented
and will not sign a DNR directive. What is the priority nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions. - ANSWER>>>When death
is impending, it is essential for the nurse to determine who is legally empowered to
make decisions regarding the use of life-saving measures for the client (D). (A) will be
abnormal and will worsen without dialysis, so are not of immediate concern. (B) may
help improve the client's quality of life prior to death, but is of less immediacy than
determining whether actions should be taken to save a client's life. If the nurse remains
unable to determine who is empowered to make decisions in this situation, the nurse
may choose to contact the ethics committee (C) for a resolution.
Correct ANSWER: D
.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?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience. -
ANSWER>>>According to states' nurse practice acts, it is the responsibility of the nurse
to function within the scope of competency (D), and in this case safe nursing practice
constitutes refusal to perform the procedure because of a lack of experience. Although
state mandates, agency policies, and continued education and experience identify tasks
that are within the scope of nursing practice, nurses should first refuse to perform tasks
,that are beyond their proficiency, and then pursue opportunities to enhance their
competency (A, B, and C).
Correct ANSWER: D
.Before administering a client's medication, the nurse assesses a change in the client's
condition and decides to withhold the medication until consulting with the healthcare
provider. After consultation with the healthcare provider, the dose of the medication is
changed and the nurse administers the newly prescribed dose an hour later than the
originally scheduled time. What action should the nurse implement in response to this
situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record. - ANSWER>>>The nurse took
the correct action and should document the events that occurred in the nurses' notes
(C). (A) did not occur and (B) is not indicated. The medication administration record is
part of the client's medical record and should be placed in the chart, (D) when no longer
current.
Correct ANSWER: C
.On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel
elimination?
A. Remind the client to turn every two hours while lying in bed.
B. Provide warm prune juice before the client goes to bed at night.
C. Teach the client to splint the incision while walking to the bathroom.
D. Administer an analgesic before the client attempts to defecate. - ANSWER>>>Prune
juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B)
facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to
relieve the client's constipation. (C) reduces discomfort during ambulation, but will not
help relieve the client's constipation. Defecation is not painful following most surgeries,
, and many analgesics used postoperatively cause constipation, so (D) is
contraindicated.
Correct ANSWER: B
The home health nurse visits an elderly client who lives at home with her husband. The
client is experiencing frequent episodes of diarrhea and bowel incontinence. Which
problem, for which the client is at risk, has the greatest priority when planning the
client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance. - ANSWER>>>Diarrhea can lead to fluid volume loss, which
is potentially life-threatening, so the highest priority is to prevent a fluid volume
imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but
these are of less potential harm than a fluid volume deficit.
Correct ANSWER: D
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?
A. Notify the surgeon that the consent form has not been signed.
B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature. -
ANSWER>>>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
(A). (B, C, and D) are not legally viable options for ensuring informed consent.
Correct ANSWER: A
FUNDAMENTALS QUESTIONS AND CORRECT DETAILED ANSWERS
ALREADY GRADED A+ 100%
A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal
insufficiency and hypertension, who gained 3 pounds in the last month. The nurse
determines that the client has been noncompliant with the diet, based on which report
from the 24-hour dietary recall? (Select all that apply.)
A. Snack of potato chips, and diet soda.
B. Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
C. Breakfast of eggs, bacon, toast, and coffee.
D. Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
E. Bedtime snack of crackers and milk. - ANSWER>>>Potato chips (A) are high in
sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only
(D) is a meal that is in compliance with a low sodium, low protein diet.
Correct ANSWER: A, B, C, E
.What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing. - ANSWER>>>The
Unna's paste boot becomes rigid after it dries, so it is important to check distally for
adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an
ace bandage may be used to cover both, but no bandage should be put under it (B).
The Unna's paste boot should be applied from the foot and wrapped towards the knee
(C). The Unna's paste boot acts as a sterile dressing, and should not be removed q8h.
Weekly removal is reasonable (D).
Correct ANSWER: A
,.A 75-year-old client who has a history of end stage renal failure and advanced lung
cancer, recently had a stroke. Two days ago the healthcare provider discontinued the
client's dialysis treatments, stating that death is inevitable, but the client is disoriented
and will not sign a DNR directive. What is the priority nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions. - ANSWER>>>When death
is impending, it is essential for the nurse to determine who is legally empowered to
make decisions regarding the use of life-saving measures for the client (D). (A) will be
abnormal and will worsen without dialysis, so are not of immediate concern. (B) may
help improve the client's quality of life prior to death, but is of less immediacy than
determining whether actions should be taken to save a client's life. If the nurse remains
unable to determine who is empowered to make decisions in this situation, the nurse
may choose to contact the ethics committee (C) for a resolution.
Correct ANSWER: D
.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?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience. -
ANSWER>>>According to states' nurse practice acts, it is the responsibility of the nurse
to function within the scope of competency (D), and in this case safe nursing practice
constitutes refusal to perform the procedure because of a lack of experience. Although
state mandates, agency policies, and continued education and experience identify tasks
that are within the scope of nursing practice, nurses should first refuse to perform tasks
,that are beyond their proficiency, and then pursue opportunities to enhance their
competency (A, B, and C).
Correct ANSWER: D
.Before administering a client's medication, the nurse assesses a change in the client's
condition and decides to withhold the medication until consulting with the healthcare
provider. After consultation with the healthcare provider, the dose of the medication is
changed and the nurse administers the newly prescribed dose an hour later than the
originally scheduled time. What action should the nurse implement in response to this
situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record. - ANSWER>>>The nurse took
the correct action and should document the events that occurred in the nurses' notes
(C). (A) did not occur and (B) is not indicated. The medication administration record is
part of the client's medical record and should be placed in the chart, (D) when no longer
current.
Correct ANSWER: C
.On the third postoperative day following thoracic surgery, a client reports feeling
constipated. Which intervention should the nurse implement to promote bowel
elimination?
A. Remind the client to turn every two hours while lying in bed.
B. Provide warm prune juice before the client goes to bed at night.
C. Teach the client to splint the incision while walking to the bathroom.
D. Administer an analgesic before the client attempts to defecate. - ANSWER>>>Prune
juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B)
facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to
relieve the client's constipation. (C) reduces discomfort during ambulation, but will not
help relieve the client's constipation. Defecation is not painful following most surgeries,
, and many analgesics used postoperatively cause constipation, so (D) is
contraindicated.
Correct ANSWER: B
The home health nurse visits an elderly client who lives at home with her husband. The
client is experiencing frequent episodes of diarrhea and bowel incontinence. Which
problem, for which the client is at risk, has the greatest priority when planning the
client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance. - ANSWER>>>Diarrhea can lead to fluid volume loss, which
is potentially life-threatening, so the highest priority is to prevent a fluid volume
imbalance (D). Diarrhea and bowel incontinence can also lead to (A, B, and C), but
these are of less potential harm than a fluid volume deficit.
Correct ANSWER: D
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?
A. Notify the surgeon that the consent form has not been signed.
B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature. -
ANSWER>>>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
(A). (B, C, and D) are not legally viable options for ensuring informed consent.
Correct ANSWER: A
