Foundations Hesi Questions
After completing an assessment and determining that a client has a problem, which action should
the nurse perform next?
A.Determine the etiology of the problem.
B. Prioritize nursing care interventions.
C. Plan appropriate interventions.
D. Collaborate with the client to set goals. - ANSWER : A. Rationale Before planning care, the nurse
should determine the etiology, or cause, of the problem, because this will help determine goals, plan
of care and priorities of interventions.
An older resident of a long-term care facility is no longer able to perform self-care and is becoming
progressively weaker. The resident previously requested that no resuscitative efforts be performed,
and the family requests hospice care. What action should the nurse implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. TrANS fer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. - ANSWER : D
Rationale
When a family requests hospice care, the nurse should first communicate with the healthcare
provider. Hospice care is provided for clients with a limited life expectancy, which must be identified
by the healthcare provider. Once the healthcare provider supports the tr ANSfer to hospice care, the
nurse can collaborate with the hospice staff and healthcare provider to determine what additional
care should be implemented.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand
are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
,D. Palpate the right radial pulse. - ANSWER : A Rationale
The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing
action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates
decreased circulation. Assessing the depth of color change and the radial pulse are also important
nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry
measures the saturation of hemoglobin with oxygen and is not indicated in situations where the
cyanosis is related to mechanical compression (the restraints).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action
should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - ANSWER : A Rationale
Foods such as eggs and milk are high biologic proteins which are allowed because they are complete
proteins and supply the essential amino acids that are necessary for growth and cell repair. Although
a low-protein diet is followed, some protein is essential. Orange juice is rich in potassium, and should
not be encouraged. The client has made a good diet choice, so classes on dietary management is not
necessary.
A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive
medications and is going to try spiritual meditation instead. What should be the nurse's first
response?
A. "It is important that you continue your medication while learning to meditate."
B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
C. "Obtain your healthcare provider's permission before starting meditation."
D. "Complementary therapy and western medicine can be effective for you." - ANSWER : A
,Rationale
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications.
However, the medications must be continued while the physiologic response to meditation is
monitored. The healthcare provider should be informed, but permission is not required to meditate.
Although it is true that this complementary therapy might be effective, it is essential that the client
continue with antihypertensive medications until the effect of meditation can be measured.
The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash
made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should
the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ANSWER : B
Rationale
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance rather than simply naming the condition.
Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to
purple skin discolorations that do not itch.
During the initial morning assessment, a male client denies dysuria but reports that his urine appears
dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C.Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ANSWER : D Rationale
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to
increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume
, deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract
infection. The client needs to restore fluid volume more than solid foods (C).
Which action is most important for the nurse to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. - ANSWER : C Rationale
Gloved hands held below waist level are considered unsterile. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis.
The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would
indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-
sodium dressing, bacon and tomato sandwich.
B. New England clam chowder, no-salt crackers, fresh fruit salad.
C. Skim milk, turkey salad, roll, vanilla ice cream.
D. Macaroni and cheese, diet Coke, a slice of cherry pie. - ANSWER : C Rationale
Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium
foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet
drinks are very high in sodium.
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen
seconds, large amounts of thick yellow secretions return. What action should the nurse implement
next?
A. Encourage the client to cough to help loosen secretions.
After completing an assessment and determining that a client has a problem, which action should
the nurse perform next?
A.Determine the etiology of the problem.
B. Prioritize nursing care interventions.
C. Plan appropriate interventions.
D. Collaborate with the client to set goals. - ANSWER : A. Rationale Before planning care, the nurse
should determine the etiology, or cause, of the problem, because this will help determine goals, plan
of care and priorities of interventions.
An older resident of a long-term care facility is no longer able to perform self-care and is becoming
progressively weaker. The resident previously requested that no resuscitative efforts be performed,
and the family requests hospice care. What action should the nurse implement first?
A. Reaffirm the client's desire for no resuscitative efforts.
B. TrANS fer the client to a hospice inpatient facility.
C. Prepare the family for the client's impending death.
D. Notify the healthcare provider of the family's request. - ANSWER : D
Rationale
When a family requests hospice care, the nurse should first communicate with the healthcare
provider. Hospice care is provided for clients with a limited life expectancy, which must be identified
by the healthcare provider. Once the healthcare provider supports the tr ANSfer to hospice care, the
nurse can collaborate with the hospice staff and healthcare provider to determine what additional
care should be implemented.
When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand
are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
,D. Palpate the right radial pulse. - ANSWER : A Rationale
The nurse has observed that a client's fingers are blue distal to a wrist restraint. The priority nursing
action is to restore circulation by loosening the restraint, because blue fingers (cyanosis) indicates
decreased circulation. Assessing the depth of color change and the radial pulse are also important
nursing interventions, but do not have the priority of removing the restraint. Pulse oximetry
measures the saturation of hemoglobin with oxygen and is not indicated in situations where the
cyanosis is related to mechanical compression (the restraints).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action
should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - ANSWER : A Rationale
Foods such as eggs and milk are high biologic proteins which are allowed because they are complete
proteins and supply the essential amino acids that are necessary for growth and cell repair. Although
a low-protein diet is followed, some protein is essential. Orange juice is rich in potassium, and should
not be encouraged. The client has made a good diet choice, so classes on dietary management is not
necessary.
A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive
medications and is going to try spiritual meditation instead. What should be the nurse's first
response?
A. "It is important that you continue your medication while learning to meditate."
B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily."
C. "Obtain your healthcare provider's permission before starting meditation."
D. "Complementary therapy and western medicine can be effective for you." - ANSWER : A
,Rationale
The prolonged practice of meditation may lead to a reduced need for antihypertensive medications.
However, the medications must be continued while the physiologic response to meditation is
monitored. The healthcare provider should be informed, but permission is not required to meditate.
Although it is true that this complementary therapy might be effective, it is essential that the client
continue with antihypertensive medications until the effect of meditation can be measured.
The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash
made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should
the nurse record this finding?
A. Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D. Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. - ANSWER : B
Rationale
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when recording
such a finding the nurse should describe the appearance rather than simply naming the condition.
Vesicles are fluid-filled blisters. Papules are solid elevated lesions and petechiae are pinpoint red to
purple skin discolorations that do not itch.
During the initial morning assessment, a male client denies dysuria but reports that his urine appears
dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C.Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ANSWER : D Rationale
Dark amber urine is characteristic of fluid volume deficit, and the client should be encouraged to
increase fluid intake (D). Caffeine, however, is a diuretic (A), and may worsen the fluid volume
, deficit. Any type of juice will be beneficial (B), since the client is not dysuric, a sign of an urinary tract
infection. The client needs to restore fluid volume more than solid foods (C).
Which action is most important for the nurse to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first. - ANSWER : C Rationale
Gloved hands held below waist level are considered unsterile. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis.
The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would
indicate to the nurse that this client understands the dietary restrictions? A. Tossed salad, low-
sodium dressing, bacon and tomato sandwich.
B. New England clam chowder, no-salt crackers, fresh fruit salad.
C. Skim milk, turkey salad, roll, vanilla ice cream.
D. Macaroni and cheese, diet Coke, a slice of cherry pie. - ANSWER : C Rationale
Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium
foods. Bacon, canned soups (especially those with seafood), hard cheeses, macaroni, and most diet
drinks are very high in sodium.
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen
seconds, large amounts of thick yellow secretions return. What action should the nurse implement
next?
A. Encourage the client to cough to help loosen secretions.
