HESI Nursing Fundamentals with 100% Verified
Answers
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?
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
,HESI Nursing Fundamentals with 100% Verified
Answers
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 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
,HESI Nursing Fundamentals with 100% Verified
Answers
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.
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.
, HESI Nursing Fundamentals with 100% Verified
Answers
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.
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.
Answers
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?
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
,HESI Nursing Fundamentals with 100% Verified
Answers
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 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
,HESI Nursing Fundamentals with 100% Verified
Answers
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.
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.
, HESI Nursing Fundamentals with 100% Verified
Answers
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.
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.
