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 - ANS A. 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 - ANS D. 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" - ANS C. "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 - ANS D. 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 - ANS B. 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 - ANS C. 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 - ANS D. the nurse notes
that there are numerous scatter rubs throughout the house
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 - ANS A. 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 - ANS D. 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" - ANS C. "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 - ANS D. 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 - ANS B. 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 - ANS C. 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 - ANS D. the nurse notes
that there are numerous scatter rubs throughout the house
