NURSING HESI FUNDAMENTALS EXAM NEWEST ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) WITH RATIONALES |ALREADY GRADED A+

NURSING HESI FUNDAMENTALS EXAM NEWEST ACTUAL EXAM COMPLETE 100 QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED ANSWERS) WITH RATIONALES |ALREADY GRADED A+ 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? A) Stage 1 pressure sore draining sero-sanguineous drainage. B) Pressure sore at bony prominence with exudate noted. C) One-inch pressure sore draining serous fluid. D) Pressure sore on heel with a small amount of purulent drainage. - Answer: C Rationale Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. As the nurse prepares the equipment to be used to start an IV on a 4-year-old boy in the treatment room, he cries continuously. What intervention should the nurse implement? Page 2/55 Crafted for Academic Insight by ©Olivia GreenWays 2025. All rights reserved. A) Take the child back to his room. B) Recruit others to restrain the child. C) Ask the mother to be present to soothe the child. D) Show the child how to manipulate the equipment. - Answer: C Rationale A 4-year-old typically has a vivid imagination and lacks concrete thinking abilities. The mother's assistance (C) can provide a stabilizing presence to help soothe the preschooler, who may perceive the invasive procedure as mutilating. To preserve the child's sense of security associated with the hospital room, it is best to perform difficult or painful procedures in another area (A). (B) may be necessary to prevent injury if the child is unable to cooperate with the mother's coaxing. (D) is best done before going to the treatment room when the child feels less threatened. On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A) Remind the client to turn every two hours while lying in bed. B) Provide warm prune juice before the client goes to bed at night. C) Teach the client to splint the incision while walking to the bathroom. D) Administer an analgesic before the client attempts to defecate. - Answer: B Rationale Prune juice is a natural laxative that stimulates peristalsis, and warming the prune juice (B) facilitates peristalsis. (A) is also helpful in promoting peristalsis but is less likely to relieve the client's constipation. (C) reduces discomfort during ambulation, but will not help relieve the client's constipation. Defecation is Page 3/55 Crafted for Academic Insight by ©Olivia GreenWays 2025. All rights reserved. not painful following most surgeries, and many analgesics used postoperatively cause constipation, so (D) is contraindicated. To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain? A) Can you describe where your pain is the most severe? B) What is your pain intensity on a scale of 1 to 10? C) Is your pain best described as aching, throbbing, or sharp? D) Which activities during a routine day are impacted by your pain? - Answer: D Rationale A client with chronic pain is more likely to have adapted physiologically to vital sign changes, localization or intensity, so pain assessment should focus on any interference with daily activities (D), such as sleep, relationships with others, physical activity, and emotional well-being. Exacerbation of acute symptoms, such as pain distribution, patterns, intensity, and descriptors elicit specific assessment findings, whereas (A, B, and C) are limiting, closed-end questions, and can be answered with a yes, no, or a number. A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24-hour dietary recall? (Select all that apply.) A) Snack of potato chips, and diet soda. B) Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee. Page 4/55 Crafted for Academic Insight by ©Olivia GreenWays 2025. All rights reserved. C) Breakfast of eggs, bacon, toast, and coffee. D) Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea. E) Bedtime snack of crackers and milk. - Answers: A, C Rationale Potato chips (A) are high in sodium. Tuna (B) is high in protein. Bacon (C) and crackers (E) are high in sodium. Only (D) is a meal that is in compliance with a low sodium, low protein diet. A client provides the nurse with information about the reason for seeking care. The nurse realizes that some information about past hospitalizations is missing. How should the nurse obtain this information? A) Solicit information on hospitalization from the insurance company. B) Look up previous medical records from archived hospital documents. C) Ask the client to discuss previous hospitalizations in the last 5 years. D) Elicit specific facts about past hospitalizations with direct questions. - Answer: D Rationale Direct questions should be used after the client's opening narrative to fill in any details that have been left out or during the review of systems to elicit specific facts about past health problems. 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? A) Apply flannel pajamas to provide warmth. B) Administer a PRN dose of ibuprofen. Page 5/55 Crafted for Academic Insight by ©Olivia GreenWays 2025. All rights reserved. C) Perform range of motion exercises in a warm tub. D) Drape the sheets over the footboard of the bed. - Answer: D Rationale The nurse should first provide an immediate comfort measure to address the client's complaint about the linens and drape the linens over the footboard of the bed (D) instead of tucking them under the mattress, which can add pressure perceived by the client as the source of her pain. (A, B, and C) may be components of the client's plan of care, but the nurse should first address the client's complaint. 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 to die. What intervention should the nurse initiate? A) Review the client's medical record for an advance directive. B) Determine if a do-not-resuscitate prescription has been obtained. C) Document that the client is being discharged against medical advice. D) Evaluate the client's mental status for competence to refuse treatment. - Answer: D Rationale Competent clients have the right to refuse treatment, so the nurse should first ensure that the client is competent (D). (A and C) are not necessary for a competent client to refuse treatment. The nurse cannot document (C) until the healthcare provider is notified of the client's wishes and a discharge prescription is obtained. A client has a nursing diagnosis of, "Spiritual distress related to a loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? Page 6/55 Crafted for Academic Insight by ©Olivia GreenWays 2025. All rights reserved. A) Help the client to accept the final stage of life. B) Assist and support the client in establishing short-term goals. C) Encourage the client to make future plans, even if they are unrealistic. D) Instruct the client's family to focus on positive aspects of the client's life. - Answer: B Rationale Hopefulness is necessary to sustain a meaningful existence, even close to death. The nurse should help the client set short-term goals, and recognize the achievement of immediate goals (B), such as seeing a family member, or listening to music. (A) is too vague to be a helpful intervention. (C) does not help the client deal with this nursing diagnosis. (D) might be implemented, but does not have the priority of (B). A male client with venous incompetence stands up and his blood pressure subsequently drops. Which finding should the nurse identify as a compensatory response? A) Bradycardia. B) Increase in pulse rate. C) Peripheral vasodilation. D) Increase in cardiac output. - Answer: B