HESI FUNDAMENTALS (By NursingHero Etsy.com)
HESI RN FUNDAMENTALS
1. A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3 days. She states, "I have been told that it is harmful to bathe during my period."
Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.: D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
2. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has
redness in the sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair.: B
Rationale: The most important teaching is to change positions frequently because pressure is
the most significant factor related to the development of pressure ulcers. Increased vitamin and
fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
3. After a needle stick occurs while removing the cap from a sterile needle, which
action should the nurse implement?
A. Complete an incident report.
B. Select another sterile needle.
C. Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately.: B
Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and
select another needle. Because the needle was sterile when the nurse was stuck and the needle
was not in contact with any other person's body fluids, the nurse does not need to complete an
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HESI FUNDAMENTALS (By NursingHero Etsy.com)
incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol
swab is not in accordance with standards for safe practice and infection control.
4. After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after
getting home. How should the nurse respond?
A. Providethe client with a list of Internet sites that answer frequently asked questions
about medications.
B. Advisethe client to obtain a current edition of a drug reference book from a local
bookstore or library.
C. Reassure the client that information about the medication is included in the written
instructions.
D. Encourage the client to call the clinic nurse or health care provider if any questions
arise.: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the
nurse or health care provider if any questions arise. Options A, B, and C may all include useful
information, but these sources of information cannot evaluate the nature of the client's
questions and the follow-up needed.
5. After the nurse tells an older client that an IV line needs to be inserted, the client becomes
very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How
should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure.: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's
apprehension. After responding calmly to the client's apprehension, the nurse may implement
to ensure safe completion of the procedure.
6. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse
to implement when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
, C. Insert an indwelling urinary catheter.
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HESI FUNDAMENTALS (By NursingHero Etsy.com)
D. Instruct client in the use of adult diapers.: A
Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing.
Option B is not necessary unless the client has an infection. Option C increases the risk of
infection. Option D does not reduce the risk of infection.
7. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of
infection?
A. Mode of transmission
B. Portal of entry
C. Reservoir
D. Portal of exit: A
Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of
the reservoir to a portal of entry.
8. A client becomes angry while waiting for a supervised break to smoke a cigarette outside
and states, "I want to go outside now and smoke. It takes forever to get anything done here!"
Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client.: D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide
concrete information about the schedule. Option A is contraindicated if the client wants to
continue smoking. Option B is insufficient to encourage a trusting relationship with the client.
Option C is preferential for this client only and is inconsistent with unit rules.
9. A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
HESI RN FUNDAMENTALS
1. A 20-year-old female client with a noticeable body odor has refused to shower for the
last 3 days. She states, "I have been told that it is harmful to bathe during my period."
Which action should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.: D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first, respecting any personal beliefs such as cultural or spiritual values.
After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.
2. A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has
redness in the sacral area. Which instruction is most important for the nurse to provide?
A. Take a vitamin supplement tablet once a day.
B. Change positions in the chair at least every hour.
C. Increase daily intake of water or other oral fluids.
D. Purchase a newer model wheelchair.: B
Rationale: The most important teaching is to change positions frequently because pressure is
the most significant factor related to the development of pressure ulcers. Increased vitamin and
fluid intake may also be beneficial and promote healing and reduce further risk. Option D is an
intervention of last resort because this will be very expensive for the client.
3. After a needle stick occurs while removing the cap from a sterile needle, which
action should the nurse implement?
A. Complete an incident report.
B. Select another sterile needle.
C. Disinfect the needle with an alcohol swab.
D. Notify the supervisor of the department immediately.: B
Rationale: After a needle stick, the needle is considered used, so the nurse should discard it and
select another needle. Because the needle was sterile when the nurse was stuck and the needle
was not in contact with any other person's body fluids, the nurse does not need to complete an
, www.etsy.com/shop/NursingHero
HESI FUNDAMENTALS (By NursingHero Etsy.com)
incident report or notify the occupational health nurse. Disinfecting a needle with an alcohol
swab is not in accordance with standards for safe practice and infection control.
4. After receiving written and verbal instructions from a clinic nurse about a newly prescribed
medication, a client asks the nurse what to do if questions arise about the medication after
getting home. How should the nurse respond?
A. Providethe client with a list of Internet sites that answer frequently asked questions
about medications.
B. Advisethe client to obtain a current edition of a drug reference book from a local
bookstore or library.
C. Reassure the client that information about the medication is included in the written
instructions.
D. Encourage the client to call the clinic nurse or health care provider if any questions
arise.: D
Rationale: To ensure safe medication use, the nurse should encourage the client to call the
nurse or health care provider if any questions arise. Options A, B, and C may all include useful
information, but these sources of information cannot evaluate the nature of the client's
questions and the follow-up needed.
5. After the nurse tells an older client that an IV line needs to be inserted, the client becomes
very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How
should the nurse respond?
A. Ask the client to remain quiet so the procedure can be performed safely.
B. Concentrate on completing the insertion as efficiently as possible.
C. Calmly reassure the client that the discomfort will be temporary.
D. Tell the client a joke as a means of distraction from the procedure.: C
Rationale: The nurse should respond with a calm demeanor to help reduce the client's
apprehension. After responding calmly to the client's apprehension, the nurse may implement
to ensure safe completion of the procedure.
6. Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse
to implement when providing care for an older incontinent client?
A. Maintain standard precautions.
B. Initiate contact isolation measures.
, C. Insert an indwelling urinary catheter.
www.etsy.com/shop/NursingHero
HESI FUNDAMENTALS (By NursingHero Etsy.com)
D. Instruct client in the use of adult diapers.: A
Rationale: The best action to decrease the risk of infection in vulnerable clients is handwashing.
Option B is not necessary unless the client has an infection. Option C increases the risk of
infection. Option D does not reduce the risk of infection.
7. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of
infection?
A. Mode of transmission
B. Portal of entry
C. Reservoir
D. Portal of exit: A
Rationale: The contaminated gloves serve as the mode of transmission from the portal of exit of
the reservoir to a portal of entry.
8. A client becomes angry while waiting for a supervised break to smoke a cigarette outside
and states, "I want to go outside now and smoke. It takes forever to get anything done here!"
Which intervention is best for the nurse to implement?
A. Encourage the client to use a nicotine patch.
B. Reassure the client that it is almost time for another break.
C. Have the client leave the unit with another staff member.
D. Review the schedule of outdoor breaks with the client.: D
Rationale: The best nursing action is to review the schedule of outdoor breaks and provide
concrete information about the schedule. Option A is contraindicated if the client wants to
continue smoking. Option B is insufficient to encourage a trusting relationship with the client.
Option C is preferential for this client only and is inconsistent with unit rules.
9. A client has a nasogastric tube connected to low intermittent suction. When administering
medications through the nasogastric tube, which action should the nurse do first?
A. Clamp the nasogastric tube.
B. Confirm placement of the tube.
C. Use a syringe to instill the medications.
