HESI RN FUNDAMENTAL EXIT
1. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's
solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300
mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and
his blood pressure is 78/48 mmHg. In addition to reporting the finding to the
surgeon. Which action should the nurse implement first? - ANSWER: d. Increase the
infusion rate of Lactated Ringer's solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). the nurse notes that
the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of
bright red blood is measured in the collection chamber. Which intervention should
the nurse implement? - ANSWER: a. Add sterile water to the suction control
chamber.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the nurse
take first? - ANSWER: c. Begin supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) - ANSWER: Headache and
tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report to
the healthcare provider? - ANSWER: d. Skin tenting occurs when the client's forearm
is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take? -
ANSWER: a. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease implemented in a rural health clinic. Which outcome indicate
the program is effective? - ANSWER: c. Clients who incurred disease complications
promptly received rehabilitation.
,8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes
that the client is having increased shortness of breath with respirations at 23
breaths/minute. Which action should the nurse implement first? - ANSWER: d.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
an immediate investigation by the nurse? - ANSWER: When I get out of bed quickly, I
feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency
department because of a COPD exacerbation. This client is struggling to breathe and
the healthcare team is preparing for endotracheal intubation. The spouse's wife,
who is 30 years younger than the client, asks the nurse to stop the procedure and
provide the nurse a copy of the client's living will. Which action should the nurse
take? - ANSWER: b. Notify the healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose prescribed activity is bedrest with bedside commode use. The UAP
reports to the nurse that the client is so obese that the UAP feels unable to safely
assist the client in transferring from the bed to the bedside commode. How should
the nurse respond? - ANSWER: c. Advice the client to maintain bedrest so that safety
can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are
overweight. The nurse presents the information at the parent-teacher meeting.
What action is most important for the nurse to include in the meeting? - ANSWER: c.
Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a young
adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes
prednisone. Which education should the nurse provide the client with regard to
taking prednisone? - ANSWER: c. If sequential doses are missed, notify the
healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client
requires the nurse's immediate attention? - ANSWER: c. An 18-year-old client with
antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit
which symptoms? - ANSWER: b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain.
The client's health history reveals peripheral atrial disease. Which question should
the nurse ask the client about expected finding related to chronic arterial
symptoms? - ANSWER: b. Does the calf pain occur when walking short distances?
, 17. The nurse is preparing to send a client to the cardiac catheterization lab for an
angioplasty. Which client report is most important for them to explore further prior
to the start of the procedure? - ANSWER: d. Experience facial swelling after eating
crab.
18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and
scaly, and the mother reports that the child frequently scratches the lesions on the
skin to the point of causing bleeding. Which guideline is indicated for care of this
child? - ANSWER: b. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her
newborn infant's crib is empty and the baby is missing. What action should the nurse
take first? - ANSWER: d. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she
frequently thinks about hurting herself. Which question is most important for the
nurse to ask? - ANSWER: c. "Have you thought about taking your life?"
21. A college student brings a dorm roommate to the campus clinic because the
roommate has been talking to someone who is not present. The client tells the nurse
that the voices are saying, "kill, kill." What question should the nurse ask the client
next? - ANSWER: c. "Are you planning to obey the voices?"
22. The nurse is developing a plan of care for a client who reports tingling of the feet
and who is newly diagnosed with peripheral vascular disease. Which outcome should
the nurse include in the plan of care for this client? - ANSWER: d. The client's skin on
the lower legs will be intact at the next clinical visit.
23. When conducting diet teaching for a client who was diagnosed with
hypertension, which food should the nurse encourage the client to eat? (select all
that apply.) - ANSWER: a. . Fruits without sauce
c. Fresh or frozen vegetables without sauce.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment
finding indication to the nurse that the client is experiencing a therapeutic response
to the phenytoin? - ANSWER: c. Absence of seizure activity for the duration of
treatment.
25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation
facility prior to discharge. Which behaviors indicate the client understands how to
maintain balance safely? (Select all that apply) - ANSWER: a. Brings a heavy can close
to body before lifting.
b. Locks knees while preparing food on the counter.
26. An older client is admitted to the hospital because of recurring transient ischemic
attacks. Neurological serial assessments for the past 24 hours were within normal
limits. One day after admission, the client suddenly becomes confused and
1. A male client with stomach cancer returns to the unit following a total
gastrectomy. He has a nasogastric tube to suction and is receiving Lactated Ringer's
solution at 75 mL/hour IV. One hour after admission to the unit, the nurse notes 300
mL of blood in the suction canister, the client's heart rate is 155 beats/minute, and
his blood pressure is 78/48 mmHg. In addition to reporting the finding to the
surgeon. Which action should the nurse implement first? - ANSWER: d. Increase the
infusion rate of Lactated Ringer's solution.
2. an adult male who fell 20 feet from the roof of this home has multiple injuries,
including a right pneumothorax. Chest tubes were inserted in the emergency
department prior to his transfer to the intensive care unit (ICU). the nurse notes that
the suction control chamber is bubbling at the
- 10 cm H2O mark, with fluctuation in the water seal, and over the past hour 75 ml of
bright red blood is measured in the collection chamber. Which intervention should
the nurse implement? - ANSWER: a. Add sterile water to the suction control
chamber.
3. A client who received hemodialysis yesterday is experiencing a blood pressure of
200/100 mmHg, heart rate 110 beats/minute, and respiratory rate 36
breaths/minute. The client is manifesting shortness of breath, bilateral 2+ pedal
edema, and an oxygen saturation on room air of 89%. Which action should the nurse
take first? - ANSWER: c. Begin supplemental oxygen.
4. A client with Addison's crisis is admitted for treatment with adrenal cortical
supplementation. Based on the client's admitting diagnosis, which findings require
immediate action by the nurse? (Select all that apply) - ANSWER: Headache and
tremors
Irregular heart rate
pallor and diaphoresis
5. An older client is admitted with fluid volume deficit and dehydration. Which
assessment finding is the best indicator of hydration that the nurse should report to
the healthcare provider? - ANSWER: d. Skin tenting occurs when the client's forearm
is pinched.
6. After an inservice about electronic health record (EHR) security and safeguarding
client information, the nurse observes a colleague going home with printed copies of
client information in a uniform pocket. Which action should the nurse take? -
ANSWER: a. File a detailed incident report with the specific hiring facility.
7. The nurse is evaluating a tertiary prevention program for clients with
cardiovascular disease implemented in a rural health clinic. Which outcome indicate
the program is effective? - ANSWER: c. Clients who incurred disease complications
promptly received rehabilitation.
,8. The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)
who uses oxygen at 2 L/minute per nasal cannula continuously. The nurse observes
that the client is having increased shortness of breath with respirations at 23
breaths/minute. Which action should the nurse implement first? - ANSWER: d.
Assess the delivery mechanism of the oxygen tank, tubing, and cannula.
9. Which statement by a client who is 24 hours post-subtotal thyroidectomy requires
an immediate investigation by the nurse? - ANSWER: When I get out of bed quickly, I
feel a little dizzy."
10. An older adult male who is in his early 70's is admitted to the emergency
department because of a COPD exacerbation. This client is struggling to breathe and
the healthcare team is preparing for endotracheal intubation. The spouse's wife,
who is 30 years younger than the client, asks the nurse to stop the procedure and
provide the nurse a copy of the client's living will. Which action should the nurse
take? - ANSWER: b. Notify the healthcare provider of the client's wishes.
11. An unlicensed assistive personnel (UAP) is assigned to provide personal care for a
client whose prescribed activity is bedrest with bedside commode use. The UAP
reports to the nurse that the client is so obese that the UAP feels unable to safely
assist the client in transferring from the bed to the bedside commode. How should
the nurse respond? - ANSWER: c. Advice the client to maintain bedrest so that safety
can be ensured.
12. A nurse determines that more than 25% of the students at a middle school are
overweight. The nurse presents the information at the parent-teacher meeting.
What action is most important for the nurse to include in the meeting? - ANSWER: c.
Distribute a shopping list of suggested healthy snack items.
13. After several months of chronic fatigue, morning stiffness, and join pain, a young
adult is diagnosed with rheumatoid arthritis, and the healthcare provider prescribes
prednisone. Which education should the nurse provide the client with regard to
taking prednisone? - ANSWER: c. If sequential doses are missed, notify the
healthcare provider.
14. The psychiatric nurse is caring for clients on an adolescent unit. Which client
requires the nurse's immediate attention? - ANSWER: c. An 18-year-old client with
antisocial behavior who is being yelled at by other clients
15. The nurse caring for a child with mononucleosis can expect the child to exhibit
which symptoms? - ANSWER: b. Ear pain and fever.
16. A client arrives for an annual physical exam and complains of having calf pain.
The client's health history reveals peripheral atrial disease. Which question should
the nurse ask the client about expected finding related to chronic arterial
symptoms? - ANSWER: b. Does the calf pain occur when walking short distances?
, 17. The nurse is preparing to send a client to the cardiac catheterization lab for an
angioplasty. Which client report is most important for them to explore further prior
to the start of the procedure? - ANSWER: d. Experience facial swelling after eating
crab.
18. The nurse is assessing a 4-year-old child with eczema. The child's skin is dry and
scaly, and the mother reports that the child frequently scratches the lesions on the
skin to the point of causing bleeding. Which guideline is indicated for care of this
child? - ANSWER: b. Apply baby lotion to the skin twice daily.
19. A new mother on the postpartum unit runs out of the room screaming that her
newborn infant's crib is empty and the baby is missing. What action should the nurse
take first? - ANSWER: d. Match ID bands of all infants and mothers on the unit.
20. While providing a health history, a female client tells the clinic nurse that she
frequently thinks about hurting herself. Which question is most important for the
nurse to ask? - ANSWER: c. "Have you thought about taking your life?"
21. A college student brings a dorm roommate to the campus clinic because the
roommate has been talking to someone who is not present. The client tells the nurse
that the voices are saying, "kill, kill." What question should the nurse ask the client
next? - ANSWER: c. "Are you planning to obey the voices?"
22. The nurse is developing a plan of care for a client who reports tingling of the feet
and who is newly diagnosed with peripheral vascular disease. Which outcome should
the nurse include in the plan of care for this client? - ANSWER: d. The client's skin on
the lower legs will be intact at the next clinical visit.
23. When conducting diet teaching for a client who was diagnosed with
hypertension, which food should the nurse encourage the client to eat? (select all
that apply.) - ANSWER: a. . Fruits without sauce
c. Fresh or frozen vegetables without sauce.
24. A client with bacterial meningitis is receiving phenytoin. Which assessment
finding indication to the nurse that the client is experiencing a therapeutic response
to the phenytoin? - ANSWER: c. Absence of seizure activity for the duration of
treatment.
25. The nurse observes a client prepare a meal in the kitchen of a rehabilitation
facility prior to discharge. Which behaviors indicate the client understands how to
maintain balance safely? (Select all that apply) - ANSWER: a. Brings a heavy can close
to body before lifting.
b. Locks knees while preparing food on the counter.
26. An older client is admitted to the hospital because of recurring transient ischemic
attacks. Neurological serial assessments for the past 24 hours were within normal
limits. One day after admission, the client suddenly becomes confused and
