HESI Fundamentals Exam with Verified
Answers
The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first?
a. assess for signs and symptoms of infection
b. palpate for a thrill
c. auscultate for a bruit
d. assess vital signs - ✔✔d. assess vital signs
Peritoneal dialysis can cause a shift in a client's fluid status, so assessment of vital signs is
necessary to be done initially to ensure an adequate, and not too much of a fluid change.
A client's caregiver is learning how to care for a client's wound and drain. Which technique of
cleansing, if taught to the caregiver, would decrease the chance of the client developing an
infection? - ✔✔Cleansing from the drain site outward away from the drainage site.
A client presents to the emergency department w/ complaints of a racing heart rate, rapid
breathing, change in appetite, difficulty concentrating, and trouble sleeping since losing their
father one month ago. Base on the client's care plan, which intervention should the nurse
include for this client? Select all that apply
CARE PLAN: Anxiety related to situational crisis (death of father) as evidenced by tachycardia,
tachypnea, changes in appetite and concentration, and disrupted sleep patterns.
CLIENT WILL:
- discuss feelings of anxiety and grief
- respond to relaxation techniques w/ a decreased anxiety level (self-reported)
- be able to reduce own anxiety level
a. administer SSRI antidepressants as needed
, b. provide reassurance and comfort measures
c. teach signs and symptoms of escalating anxiety
d. encourage the client's participation in relaxation exercises
e. encourage the client to talk about traumatic experie - ✔✔b. provide reassurance and
comfort measures
c. teach signs and symptoms of escalating anxiety
d. encourage the client's participation in relaxation exercises
e. encourage the client to talk about traumatic experiences in a supportive environment
The nurse learns that a client who is 6 days postpartum has persistent lochia rubra. what do
these assessment findings suggest to the nurse?
a. coagulation disorder
b. cervical laceration
c. retained placental fragments
d. over-adequate uterine contraction - ✔✔c. retained placental fragments
During the first 3 days after delivery vaginal discharge is bright red, bloody, and sometimes
streaked w/ clots. This is called lochia rubra. After 3 days the vaginal discharge becomes pink in
color and is called lochia serosa. Persistent lochia rubra can be caused by inadequate uterine
contraction, retained placental fragments and infection.
The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best
to promote independence in this client?
a. measure orthostatic vital signs
b. obtain order for costisol level
c. initiate workup for diabetes insipidus
d. review most recent sodium level - ✔✔d. review most recent sodium level
Answers
The healthcare provider performs peritoneal dialysis on a client, after which 2 liters of fluid is
drained. What action should the nurse complete first?
a. assess for signs and symptoms of infection
b. palpate for a thrill
c. auscultate for a bruit
d. assess vital signs - ✔✔d. assess vital signs
Peritoneal dialysis can cause a shift in a client's fluid status, so assessment of vital signs is
necessary to be done initially to ensure an adequate, and not too much of a fluid change.
A client's caregiver is learning how to care for a client's wound and drain. Which technique of
cleansing, if taught to the caregiver, would decrease the chance of the client developing an
infection? - ✔✔Cleansing from the drain site outward away from the drainage site.
A client presents to the emergency department w/ complaints of a racing heart rate, rapid
breathing, change in appetite, difficulty concentrating, and trouble sleeping since losing their
father one month ago. Base on the client's care plan, which intervention should the nurse
include for this client? Select all that apply
CARE PLAN: Anxiety related to situational crisis (death of father) as evidenced by tachycardia,
tachypnea, changes in appetite and concentration, and disrupted sleep patterns.
CLIENT WILL:
- discuss feelings of anxiety and grief
- respond to relaxation techniques w/ a decreased anxiety level (self-reported)
- be able to reduce own anxiety level
a. administer SSRI antidepressants as needed
, b. provide reassurance and comfort measures
c. teach signs and symptoms of escalating anxiety
d. encourage the client's participation in relaxation exercises
e. encourage the client to talk about traumatic experie - ✔✔b. provide reassurance and
comfort measures
c. teach signs and symptoms of escalating anxiety
d. encourage the client's participation in relaxation exercises
e. encourage the client to talk about traumatic experiences in a supportive environment
The nurse learns that a client who is 6 days postpartum has persistent lochia rubra. what do
these assessment findings suggest to the nurse?
a. coagulation disorder
b. cervical laceration
c. retained placental fragments
d. over-adequate uterine contraction - ✔✔c. retained placental fragments
During the first 3 days after delivery vaginal discharge is bright red, bloody, and sometimes
streaked w/ clots. This is called lochia rubra. After 3 days the vaginal discharge becomes pink in
color and is called lochia serosa. Persistent lochia rubra can be caused by inadequate uterine
contraction, retained placental fragments and infection.
The nurse is caring for a client diagnosed with myasthenia gravis. Which nursing action is best
to promote independence in this client?
a. measure orthostatic vital signs
b. obtain order for costisol level
c. initiate workup for diabetes insipidus
d. review most recent sodium level - ✔✔d. review most recent sodium level
