HESI Fundamentals Practice Exam 2024

The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? Ask the client to relax and run a small amount of fluid into the rectum. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? Vitamin B12. An older client who is able to stand but not to 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? Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? Combination of plant proteins to provide essential amino acids. 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? "It may hurt but we'll give you medicine to help you feel better." When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? "What is concerning you this morning?" Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? Upon discharge, the client will list three ways to protect the feet from injury. The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? Cradle the client's heel. While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? Instruct the client to take slow deep breaths and stop bearing down. What action should the nurse implement when adding sterile liquids to a sterile field? Consider the sterile field contaminated if it becomes wet during the procedure. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? Continue the planned nursing interventions to restore the client's fluid volume. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? Take measures to promote as much comfort as possible. 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? Draw up the irrigating solution into the syringe. The nurse is administering an intermittent infusion of an antibiotic to a client who’s intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? Reposition the client's arm. 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? Check capillary refill of toes on lower extremity with Unna's paste boot. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? Wet to moist dressing. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? Herbs should be obtained from manufacturers with a history of quality control of their supplements. 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? One-inch pressure sore draining serous fluid. 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? Refuse to perform the task that is beyond the nurse's experience. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? Sensory pattern, area, intensity, and nature of the pain. What action by the nurse demonstrates culturally sensitive care? Asks permission before touching a client. A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? Inform the family that death is imminent. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented? Continue gabapentin. When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? Flush the lumen with the saline solution and administer the medication through the lumen. How should the nurse handle linens that are soiled with incontinent feces? Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? Drape the sheets over the footboard of the bed. A healthcare provider is performing a sterile procedure at a client’s bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? Identify the break in surgical asepsis and provide another set of sterile supplies. The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care? Risk for aspiration. In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? Document the presence and volume of the pulse palpated. A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? "I will ask one of the female nurses to bathe you." Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? Use reflective listening techniques when the client expresses spiritual doubts. During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? Degree of flexion and extension of the client's knee joint. The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? Upper torso. An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Rashes in the axillary, groin, and skin fold regions. Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? Instruct the client that the stoma will become smaller when the initial swelling diminishes. The nurse observes an unlicensed assistive personnel (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement? Reassess the client's blood pressure using a larger cuff. A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) 2 A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge? Demonstrating the wound care procedure correctly. A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.) 2 A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.) 2 An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? The nurse who transferred the client to the chair when the fall occurred. The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A lactating woman nursing her 3-day-old infant. 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? Notify the healthcare provider of the family's request. The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? Avoid any types of sprays, powders, and perfumes. A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? Ensure the accuracy of the blood type match. The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? Report the results of the vital signs to the nurse. During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? Use the stethoscope bell over the valvular areas of the anterior chest. The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? "Hot" remedies restore balance after surgery, which is considered a "cold" condition. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? Assess for bladder distention. A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take? Commend the client for selecting a high biologic value protein. When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first? Note which actions were not implemented. Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? Accepts that punishment from God is not related to illness. 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? Loosen the right wrist restraint. A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? "What vitamin and mineral supplements do you take?"