HESI - Fundamentals practice questions
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the
AV node."
Explanation:
The PR interval is measured from the beginning of the P wave to the beginning of the QRS
complex and represents the time needed for sinus node stimulation, atrial depolarization, and
conduction through the AV node before ventricular depolarization. In a normal heart the
impulses do not travel backward. The PR interval does not include the time it take to travel
through the Purkinje fibers - ANS-P-R interval
\0.24 seconds
Explanation:
In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds
would indicate a first-degree heart block. - ANS-Which PR interval presents a first-degree heart
block?
\3 checks of safe medication administration - ANS-1) Before you pour, mix, or draw up a
medication
2) After you prepare the medication
3) At the bedside
\5 stages of infection - ANS-Incubation, prodromal, illness, decline, convalescence
\64.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. - ANS-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.
Correct Answer: A, B, C, E
\65.What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing. - ANS-The Unna's paste boot
becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix
is often wrapped around the outside of the boot and an ace bandage may be used to cover
both, but no bandage should be put under it (B). The Unna's paste boot should be applied from
,the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing,
and should not be removed q8h. Weekly removal is reasonable (D).
Correct Answer: A
\66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer,
recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis
treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR
directive. What is the priority nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions. - ANS-When death is impending, it
is essential for the nurse to determine who is legally empowered to make decisions regarding
the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without
dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to
death, but is of less immediacy than determining whether actions should be taken to save a
client's life. If the nurse remains unable to determine who is empowered to make decisions in
this situation, the nurse may choose to contact the ethics committee (C) for a resolution.
Correct Answer: D
\67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously
performed the procedure. What action is most important for the new staff nurse to take?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience. - ANS-According to states'
nurse practice acts, it is the responsibility of the nurse to function within the scope of
competency (D), and in this case safe nursing practice constitutes refusal to perform the
procedure because of a lack of experience. Although state mandates, agency policies, and
continued education and experience identify tasks that are within the scope of nursing practice,
nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue
opportunities to enhance their competency (A, B, and C).
Correct Answer: D
\68.Before administering a client's medication, the nurse assesses a change in the client's
condition and decides to withhold the medication until consulting with the healthcare provider.
After consultation with the healthcare provider, the dose of the medication is changed and the
nurse administers the newly prescribed dose an hour later than the originally scheduled time.
What action should the nurse implement in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record. - ANS-The nurse took the correct
action and should document the events that occurred in the nurses' notes (C). (A) did not occur
and (B) is not indicated. The medication administration record is part of the client's medical
record and should be placed in the chart, (D) when no longer current.
Correct Answer: C
,\69.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. - ANS-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.
Correct Answer: B
\70.The home health nurse visits an elderly client who lives at home with her husband. The
client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for
which the client is at risk, has the greatest priority when planning the client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance. - ANS-Diarrhea can lead to fluid volume loss, which is potentially
life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and
bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a
fluid volume deficit.
Correct Answer: D
\71.After a client has been premedicated for surgery with an opioid analgesic, the nurse
discovers that the operative permit has not been signed. What action should the nurse
implement?
A. Notify the surgeon that the consent form has not been signed.
B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature. - ANS-Once a client
has been premedicated for surgery with any type of sedative, legal informed consent is not
possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options
for ensuring informed consent.
Correct Answer: A
\72.A client who has been on bedrest for several days now has a prescription to progress
activity as tolerated. When the nurse assists the client out of bed for the first time, the client
becomes dizzy. What action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is contacted.
D. Advise the client to sit on the side of the bed for a few minutes before standing again. -
ANS-The nurse should implement (D), because orthostatic hypotension is a common result of
immobilization, causing the client to feel dizzy when first getting out of bed following a period of
bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position
, by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to
alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will
increase the potential for complications associated with prolonged immobility.
Correct Answer: D
\74.A client is admitted to the hospital with intractable pain. What instruction should the nurse
provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a
bed bath?
A. Take measures to promote as much comfort as possible.
B. Report any signs of drug addiction to the nurse immediately.
C. Wait until the client's pain is gone before assisting with personal care.
D. This client's pain will be difficult to manage, since the cause is unknown. - ANS-Intractable
pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during
all activities. A client with intractable pain may develop drug tolerance and dependence, but (B)
is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be
possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause.
Correct Answer: A
\75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of
the knee. He tells the nurse that he has already given verbal consent for the procedure to the
healthcare provider. What action should the nurse implement?
A. Witness the client's signature on the consent form.
B. Verify the client's consent with the healthcare provider.
C. Notify the healthcare provider that the client is ready for the procedure.
D. Document that the client has given consent for the needle aspiration. - ANS-Written informed
consent is required prior to any invasive procedure. The healthcare provider must explain the
procedure to the client, but the nurse can witness the client's signature on a consent form (A).
(B) is not necessary since written consent must be obtained. (C) is not correct because written
consent has not been obtained. (D) must occur after written consent is obtained.
Correct Answer: A
\76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation
while the client is in a supine position. What action should the nurse implement?
A. Elevate the head of the bed and attempt to palpate the site again.
B. Document the presence and volume of the pulse palpated.
C. Use a thigh cuff to measure the blood pressure in the leg.
D. Record the presence of pitting edema in the inguinal area. - ANS-Deep palpation may be
required to palpate the femoral pulse; and, when palpated, the nurse should document the
presence and volume of the pulse (B). The site is best palpated with the client supine; elevation
of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the
femoral pulse does not indicate a problem requiring further assessment, such as (C), and does
not reflect the presence of edema (D).
Correct Answer: B
\77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal
bleeding. What action should the nurse implement?
A. Administer the medication as scheduled after assessing the client's vital signs.
B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit.
"It shows the time needed for the SA node impulse to depolarize the atria and travel through the
AV node."
Explanation:
The PR interval is measured from the beginning of the P wave to the beginning of the QRS
complex and represents the time needed for sinus node stimulation, atrial depolarization, and
conduction through the AV node before ventricular depolarization. In a normal heart the
impulses do not travel backward. The PR interval does not include the time it take to travel
through the Purkinje fibers - ANS-P-R interval
\0.24 seconds
Explanation:
In adults, the normal range for the PR is 0.12 to 0.20 seconds. A PR internal of 0.24 seconds
would indicate a first-degree heart block. - ANS-Which PR interval presents a first-degree heart
block?
\3 checks of safe medication administration - ANS-1) Before you pour, mix, or draw up a
medication
2) After you prepare the medication
3) At the bedside
\5 stages of infection - ANS-Incubation, prodromal, illness, decline, convalescence
\64.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. - ANS-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.
Correct Answer: A, B, C, E
\65.What intervention should the nurse include in the plan of care for a client who is being
treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?
A. Check capillary refill of toes on lower extremity with Unna's paste boot.
B. Apply dressing to wound area before applying the Unna's paste boot.
C. Wrap the leg from the knee down towards the foot.
D. Remove the Unna's paste boot q8h to assess wound healing. - ANS-The Unna's paste boot
becomes rigid after it dries, so it is important to check distally for adequate circulation (A). Kerlix
is often wrapped around the outside of the boot and an ace bandage may be used to cover
both, but no bandage should be put under it (B). The Unna's paste boot should be applied from
,the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile dressing,
and should not be removed q8h. Weekly removal is reasonable (D).
Correct Answer: A
\66.A 75-year-old client who has a history of end stage renal failure and advanced lung cancer,
recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis
treatments, stating that death is inevitable, but the client is disoriented and will not sign a DNR
directive. What is the priority nursing intervention?
A. Review the client's most recent laboratory reports.
B. Refer the client and family members for hospice care.
C. Notify the hospital ethics committee of the client situation.
D. Determine who is legally empowered to make decisions. - ANS-When death is impending, it
is essential for the nurse to determine who is legally empowered to make decisions regarding
the use of life-saving measures for the client (D). (A) will be abnormal and will worsen without
dialysis, so are not of immediate concern. (B) may help improve the client's quality of life prior to
death, but is of less immediacy than determining whether actions should be taken to save a
client's life. If the nurse remains unable to determine who is empowered to make decisions in
this situation, the nurse may choose to contact the ethics committee (C) for a resolution.
Correct Answer: D
\67.The charge nurse assigns a nursing procedure to a new staff nurse who has not previously
performed the procedure. What action is most important for the new staff nurse to take?
A. Review the steps in the procedure manual.
B. Ask another nurse to assist while implementing the procedure.
C. Follow the agency's policy and procedure.
D. Refuse to perform the task that is beyond the nurse's experience. - ANS-According to states'
nurse practice acts, it is the responsibility of the nurse to function within the scope of
competency (D), and in this case safe nursing practice constitutes refusal to perform the
procedure because of a lack of experience. Although state mandates, agency policies, and
continued education and experience identify tasks that are within the scope of nursing practice,
nurses should first refuse to perform tasks that are beyond their proficiency, and then pursue
opportunities to enhance their competency (A, B, and C).
Correct Answer: D
\68.Before administering a client's medication, the nurse assesses a change in the client's
condition and decides to withhold the medication until consulting with the healthcare provider.
After consultation with the healthcare provider, the dose of the medication is changed and the
nurse administers the newly prescribed dose an hour later than the originally scheduled time.
What action should the nurse implement in response to this situation?
A. Notify the charge nurse that a medication error occurred.
B. Submit a medication variance report to the supervisor.
C. Document the events that occurred in the nurses' notes.
D. Discard the original medication administration record. - ANS-The nurse took the correct
action and should document the events that occurred in the nurses' notes (C). (A) did not occur
and (B) is not indicated. The medication administration record is part of the client's medical
record and should be placed in the chart, (D) when no longer current.
Correct Answer: C
,\69.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. - ANS-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.
Correct Answer: B
\70.The home health nurse visits an elderly client who lives at home with her husband. The
client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for
which the client is at risk, has the greatest priority when planning the client's care?
A. Disturbed sleep pattern.
B. Caregiver role strain.
C. Impaired skin integrity.
D. Fluid volume imbalance. - ANS-Diarrhea can lead to fluid volume loss, which is potentially
life-threatening, so the highest priority is to prevent a fluid volume imbalance (D). Diarrhea and
bowel incontinence can also lead to (A, B, and C), but these are of less potential harm than a
fluid volume deficit.
Correct Answer: D
\71.After a client has been premedicated for surgery with an opioid analgesic, the nurse
discovers that the operative permit has not been signed. What action should the nurse
implement?
A. Notify the surgeon that the consent form has not been signed.
B. Read the consent form to the client before witnessing the client's signature.
C. Determine if the client's spouse is willing to sign the consent form.
D. Administer an opioid antagonist prior to obtaining the client's signature. - ANS-Once a client
has been premedicated for surgery with any type of sedative, legal informed consent is not
possible, so the nurse must notify the surgeon (A). (B, C, and D) are not legally viable options
for ensuring informed consent.
Correct Answer: A
\72.A client who has been on bedrest for several days now has a prescription to progress
activity as tolerated. When the nurse assists the client out of bed for the first time, the client
becomes dizzy. What action should the nurse implement?
A. Encourage the client to take several slow, deep breaths while ambulating.
B. Help the client to remain standing by the bedside until the dizziness is relieved.
C. Instruct the client to remain on bedrest until the healthcare provider is contacted.
D. Advise the client to sit on the side of the bed for a few minutes before standing again. -
ANS-The nurse should implement (D), because orthostatic hypotension is a common result of
immobilization, causing the client to feel dizzy when first getting out of bed following a period of
bedrest. To prevent this problem, it is helpful to have the body acclimate to a standing position
, by sitting upright for a short period (D) before rising to a standing position. (A) is unlikely to
alleviate the dizziness. (B) may result in a loss of consciousness. (C) is not indicated and will
increase the potential for complications associated with prolonged immobility.
Correct Answer: D
\74.A client is admitted to the hospital with intractable pain. What instruction should the nurse
provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a
bed bath?
A. Take measures to promote as much comfort as possible.
B. Report any signs of drug addiction to the nurse immediately.
C. Wait until the client's pain is gone before assisting with personal care.
D. This client's pain will be difficult to manage, since the cause is unknown. - ANS-Intractable
pain is highly resistant to pain relief measures, so it is important to promote comfort (A) during
all activities. A client with intractable pain may develop drug tolerance and dependence, but (B)
is inappropriate for a UAP. Since intractable pain is resistant to relief measures, (C) may not be
possible. Psychogenic pain (D) is a painful sensation that is perceived but has no known cause.
Correct Answer: A
\75.A male client arrives at the outpatient surgery center for a scheduled needle aspiration of
the knee. He tells the nurse that he has already given verbal consent for the procedure to the
healthcare provider. What action should the nurse implement?
A. Witness the client's signature on the consent form.
B. Verify the client's consent with the healthcare provider.
C. Notify the healthcare provider that the client is ready for the procedure.
D. Document that the client has given consent for the needle aspiration. - ANS-Written informed
consent is required prior to any invasive procedure. The healthcare provider must explain the
procedure to the client, but the nurse can witness the client's signature on a consent form (A).
(B) is not necessary since written consent must be obtained. (C) is not correct because written
consent has not been obtained. (D) must occur after written consent is obtained.
Correct Answer: A
\76.In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation
while the client is in a supine position. What action should the nurse implement?
A. Elevate the head of the bed and attempt to palpate the site again.
B. Document the presence and volume of the pulse palpated.
C. Use a thigh cuff to measure the blood pressure in the leg.
D. Record the presence of pitting edema in the inguinal area. - ANS-Deep palpation may be
required to palpate the femoral pulse; and, when palpated, the nurse should document the
presence and volume of the pulse (B). The site is best palpated with the client supine; elevation
of the head of the bed requires even deeper palpation (A). The use of deep palpation to feel the
femoral pulse does not indicate a problem requiring further assessment, such as (C), and does
not reflect the presence of edema (D).
Correct Answer: B
\77.A nurse is preparing to insert a rectal suppository and observes a small amount of rectal
bleeding. What action should the nurse implement?
A. Administer the medication as scheduled after assessing the client's vital signs.
B. Ask the pharmacist to send an alternate form of the prescribed medication to the unit.
