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Exam (elaborations)

HESI RN FUNDAMENTAL EXIT

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HESI RN FUNDAMENTAL EXIT

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HESI RN FUNDAMENTAL EXIT
In planning care for a 6 month-old infant, what must the nurse provide to assist in
the development of trust?
A) Food
B) Warmth
C) Security
D) Comfort - ANSWER: C) Security

A nurse has just received a medication order which is not legible. Which statement
best reflects assertive communication?
A) "I cannot give this medication as it is written. I have no idea of what you mean."
B) "Would you please clarify what you have written so I am sure I am reading it
correctly?"
C) "I am having difficulty reading your handwriting. It would save me time if you
would be more careful."
D) "Please print in the future so I do not have to spend extra time attempting to read
your writing." - ANSWER: B) "Would you please clarify what you have written so I am
sure I am reading it
correctly?"

What is the most important consideration when teaching parents how to reduce
risks in the home?
A) Age and knowledge level of the parents
B) Proximity to emergency services
C) Number of children in the home
D) Age of children in the home - ANSWER: D) Age of children in the home

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the
nurse enters the room to request something for pain. The nurse should
A) Administer a placebo
B) Encourage increased fluid intake
C) Administer the prescribed analgesia
D) Recommend relaxation exercises for pain control - ANSWER: C) Administer the
prescribed analgesia

While caring for a toddler with croup, which initial sign of croup requires the nurse's
immediate attention?
A) Respiratory rate of 42
B) Lethargy for the past hour
C) Apical pulse of 54
D) Coughing up copious secretions - ANSWER: A) Respiratory rate of 42

A client is admitted with low T3 and T4 levels and an elevated TSH level. On initial
assessment, the nurse would anticipate which of the following assessment findings?
A) Lethargy
B) Heat intolerance

,C) Diarrhea
D) Skin eruptions - ANSWER: A) Lethargy

The emergency room nurse admits a child who experienced a seizure at school. The
father comments that this is the first occurrence, and denies any family history of
epilepsy. What is the best response by the nurse?
A) "Do not worry. Epilepsy can be treated with medications."
B) "The seizure may or may not mean your child has epilepsy."
C) "Since this was the first convulsion, it may not happen again."
D) "Long term treatment will prevent future seizures." - ANSWER: B) "The seizure
may or may not mean your child has epilepsy."

Alcohol and drug abuse impairs judgment and increases risk taking behavior. What
nursing diagnosis best applies?
A) Risk for injury
B) Risk for knowledge deficit
C) Altered thought process
D) Disturbance in self-esteem - ANSWER: A) Risk for injury

Which these findings would the nurse more closely associate with anemia in a 10
month-old infant?
A) Hemoglobin level of 12 g/dI
B) Pale mucosa of the eyelids and lips
C) Hypoactivity
D) A heart rate between 140 to 160 - ANSWER: B) Pale mucosa of the eyelids and lips

The nurse is caring for a client in hypertensive crisis in an intensive care unit. The
priority assessment in the first hour of care is
A) Heart rate
B) Pedal pulses
C) Lung sounds
D) Pupil responses - ANSWER: D) Pupil responses

Which of these clients who are all in the terminal stage of cancer is least appropriate
to suggest the use of patient controlled analgesia (PCA) with a pump?
A) A young adult with a history of Down's syndrome
B) A teenager who reads at a 4th grade level
C) An elderly client with numerous arthritic nodules on the hands
D) A preschooler with intermittent episodes of alertness - ANSWER: D) A preschooler
with intermittent episodes of alertness

The nurse is about to assess a 6 month-old child with nonorganic failure-to thrive
(NOFTT). Upon entering the room, the nurse would expect the baby to be
A) Irritable and "colicky" with no attempts to pull to standing
B) Alert, laughing and playing with a rattle, sitting with support
C) Skin color dusky with poor skin turgor over abdomen

, D) Pale, thin arms and legs, uninterested in surroundings - ANSWER: D) Pale, thin
arms and legs, uninterested in surroundings

As the nurse is speaking with a group of teens which of these side effects of
chemotherapy for cancer would the nurse expect this group to be more interested in
during the discussion?
A) Mouth sores
B) Fatigue
C) Diarrhea
D) Hair loss - ANSWER: D) Hair loss

While caring for a client who was admitted with myocardial infarction (MI) 2 days
ago, the nurse notes today's temperature is 101.1 degrees Fahrenheit (38.5
degreesCelsius). The appropriate nursing intervention is to
A) Call the health care provider immediately
B) Administer acetaminophen as ordered as this is normal at this time
C) Send blood, urine and sputum for culture
D) Increase the client's fluid intake - ANSWER: B) Administer acetaminophen as
ordered as this is normal at this time

A client is admitted for first and second degree burns on the face, neck, anterior
chest and hands. The nurse's priority should be
A) Cover the areas with dry sterile dressings
B) Assess for dyspnea or stridor
C) Initiate intravenous therapy
D) Administer pain medication - ANSWER: B) Assess for dyspnea or stridor

Which of these clients who call the community health clinic would the nurse ask to
come in that day to be seen by the health care provider?
A) I started my period and now my urine has turned bright red.
B) I am an diabetic and today I have been going to the bathroom every hour.
C) I was started on medicine yesterday for a urine infection. Now my lower belly
hurts when I go to the bathroom.
D) I went to the bathroom and my urine looked very red and it didn't hurt when I
went. - ANSWER: D) I went to the bathroom and my urine looked very red and it
didn't hurt when I went.

Which of these parents' comment for a newborn would most likely reveal an initial
finding of a suspected pyloric stenosis?
A) I noticed a little lump a little above the belly button.
B) The baby seems hungry all the time.
C) Mild vomiting that progressed to vomiting shooting across the room.
D) Irritation and spitting up immediately after feedings. - ANSWER: C) Mild vomiting
that progressed to vomiting shooting across the room.

The nurse is assessing a child for clinical manifestations of iron deficiency anemia.
Which factor would the nurse recognize as cause for the findings?
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