HESI RN FUNDAMENTALS f f
1. When turning an immobile bedridden client without assistance, which action by
f f f f f f f f f f f
the nurse best ensures client safety?f f f f f
f
A. Securely grasp the client's arm and leg.
f f f f f f f
f
B. Put bed rails up on the side of bed opposite from the nurse.
f f f f f f f f f f f f f
f
C. Correctly position and use a turn sheet.
f f f f f f f
f
D. Lower the head of the client's bed slowly.
f f f f f f f f
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the op
f f f f f f f f f f f f f f f f f f f
posite side to ensure that the client does not fall out of bed. Option A can cause client inj
f f f f f f f f f f f f f f f f f f
ury to the skin or joint. Options C and D are useful techniques while turning a client but
f f f f f f f f f f f f f f f f f f
have less priority in terms of safety than use of the bed rails.
f f f f f f f f f f f f
2. The nurse identifies a potential for infection in a client with partial-
f f f f f f f f f f f
thickness (second-degree) and full-thickness (third- f f f f
degree) burns. What intervention has the highest priority in decreasing the client
f f f f f f f f f f f
's risk of infection?f f f
f
A. Administration of plasma expanders
f f f f
f
B. Use of careful handwashing technique
f f f f f
f
C. Application of a topical antibacterial cream
f f f f f f
f
D. Limiting visitors to the client with burns
f f f f f f f
Rationale:
Careful handwashing technique is the single most effective intervention for the prevent
f f f f f f f f f f f
ion of contamination to all clients. Option A reverses the hypovolemia that initially acc
f f f f f f f f f f f f f
ompanies burn trauma but is not related to decreasing the proliferation of infective orga
f f f f f f f f f f f f f
nisms. Options C and D are recommended by various burn centers as possible ways to r
f f f f f f f f f f f f f f f
educe the chance of infection. Option B is a proven technique to prevent infection.
f f f f f f f f f f f f f
3. The nurse is aware that malnutrition is a common problem among clients served
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by a community health clinic for the homeless. Which laboratory value is the mo
f f f f f f f f f f f f f
st reliable indicator of chronic protein malnutrition?
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,f
A. Low serum albumin level
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f
B. Low serum transferrin level
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f
C. High hemoglobin level
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f
D. High cholesterol level
f f f
Rationale:
Long-
term protein deficiency is required to cause significantly lowered serum albumin levels
f f f f f f f f f f f
. Albumin is made by the liver only when adequate amounts of amino acids (from protei
f f f f f f f f f f f f f f f
n breakdown) are available. Albumin has a long half-
f f f f f f f f
life, so acute protein loss does not significantly alter serum levels. Option B is a serum p
f f f f f f f f f f f f f f f f
rotein with a half- f f f
life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and
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D are not clinical measures of protein malnutrition.
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4. In completing a client's preoperative routine, the nurse finds that the operative pe
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rmit is not signed. The client begins to ask more questions about the surgical proc
f f f f f f f f f f f f f f
edure. Which action should the nurse take next? f f f f f f f
f
A Witness the client's signature to the permit.
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.
f
B Answer the client's questions about the surgery.
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.
f
C Inform the surgeon that the operative permit is not signed and the client has questio
f f f f f f f f f f f f f f f
. ns about the surgery. f f f
f
D Reassure the client that the surgeon will answer any questions before the anesthesi
f f f f f f f f f f f f f
. a is administered. f f
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the surg
f f f f f f f f f f f f f f f
eon's responsibility to explain the procedure to the client and obtain the client's signatur
f f f f f f f f f f f f f
e on the permit. Although the nurse can witness an operative permit, the procedure mus
f f f f f f f f f f f f f f
t first be explained by the health care provider or surgeon, including answering the clien
f f f f f f f f f f f f f f
t's questions. The client's questions should be addressed before the permit is signed.
f f f f f f f f f f f f
, 5. The nurse is assessing several clients prior to surgery. Which factor in a client's h
f f f f f f f f f f f f f f
istory poses the greatest threat for complications to occur during surgery?
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f
A. Taking birth control pills for the past 2 years
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f
B. Taking anticoagulants for the past year
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f
C. Recently completing antibiotic therapy
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f
D. Having taken laxatives PRN for the last 6 months
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Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat fo f f f f f f f f f f f f f
r the development of surgical complications. The health care provider should be inform
f f f f f f f f f f f f
ed that the client is taking these drugs. Although clients who take birth control pills may
f f f f f f f f f f f f f f f f
be more susceptible to the development of thrombi, such problems usually occur posto
f f f f f f f f f f f f
peratively. A client with option C or D is at less of a surgical risk than with option B.
f f f f f f f f f f f f f f f f f f
6. When assisting a client from the bed to a chair, which procedure is best for the nu
f f f f f f f f f f f f f f f f
rse to follow? f f
f f
A Place the chair parallel to the bed, with its back toward the head of the bed and assist
f f f f f f f f f f f f f f f f f f
. the client in moving to the chair.
f f f f f f
f
B With the nurse's feet spread apart and knees aligned with the client's knees, stand an
f f f f f f f f f f f f f f f
. d pivot the client into the chair.
f f f f f f
f
C Assist the client to a standing position by gently lifting upward, underneath the axill
f f f f f f f f f f f f f f
. ae.
f f
D Stand beside the client, place the client's arms around the nurse's neck, and gently m
f f f f f f f f f f f f f f
. ove the client to the chair. f f f f f
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide bas
f f f f f f f f f f f f f f f
e of support while stabilizing the client's knees when assisting to a standing position. Th
f f f f f f f f f f f f f f
e chair should be placed at a 45-
f f f f f f f
degree angle to the bed, with the back of the chair toward the head of the bed. Clients sh
f f f f f f f f f f f f f f f f f f
ould never be lifted under the axillae; this could damage nerves and strain the nurse's ba
f f f f f f f f f f f f f f f
ck. The client should be instructed to use the arms of the chair and should never place hi
f f f f f f f f f f f f f f f f f
s or her arms around the nurse's neck; this places undue stress on the nurse's neck and ba
f f f f f f f f f f f f f f f f f
ck and increases the risk for a fall.
f f f f f f f
7.Which step(s) should the nurse take when administering ear drops to an adult clien
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t? (Select all that apply.)
f f f f
, f
A. Place the client in a side-lying position.
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f
B. Pull the auricle upward and outward.
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f
C. Hold the dropper 6 cm above the ear canal.
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f
D. Place a cotton ball into the inner canal.
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f
E. Pull the auricle down and back.
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Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The drop
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per should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed
f f f f f f f f f f f f f f f f f f f
in the outermost canal (D). The auricle is pulled down and back for a child younger than
f f f f f f f f f f f f f f f f f
3 years of age, but not an adult (E).
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8.The nurse is instructing a client in the proper use of a metered-
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dose inhaler. Which instruction should the nurse provide the client to ensure the optima
f f f f f f f f f f f f f
l benefits from the drug?
f f f f
f
A. "Fill your lungs with air through your mouth and then compress the inhaler."
f f f f f f f f f f f f f
f
B. "Compress the inhaler while slowly breathing in through your mouth."
f f f f f f f f f f
f
C. "Compress the inhaler while inhaling quickly through your nose."
f f f f f f f f f
f
D. "Exhale completely after compressing the inhaler and then inhale."
f f f f f f f f f
Rationale:
The medication should be inhaled through the mouth simultaneously with compressio
f f f f f f f f f f
n of the inhaler. This will facilitate the desired destination of the aerosol medication dee
f f f f f f f f f f f f f f
p in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow fo
f f f f f f f f f f f f f f f f f
r deep lung penetration
f f f
9. A 20-year-
f f
old female client with a noticeable body odor has refused to shower for the last 3 days. S
f f f f f f f f f f f f f f f f f
he states, "I have been told that it is harmful to bathe during my period." Which action s
f f f f f f f f f f f f f f f f f
hould the nurse take first? f f f f
f
A. Accept and document the client's wish to refrain from bathing.
f f f f f f f f f f
f
B. Offer to give the client a bed bath, avoiding the perineal area.
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f
C. Obtain written brochures about menstruation to give to the client.
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f
D. Teach the importance of personal hygiene during menstruation with the client.
f f f f f f f f f f f
1. When turning an immobile bedridden client without assistance, which action by
f f f f f f f f f f f
the nurse best ensures client safety?f f f f f
f
A. Securely grasp the client's arm and leg.
f f f f f f f
f
B. Put bed rails up on the side of bed opposite from the nurse.
f f f f f f f f f f f f f
f
C. Correctly position and use a turn sheet.
f f f f f f f
f
D. Lower the head of the client's bed slowly.
f f f f f f f f
Rationale:
Because the nurse can only stand on one side of the bed, bed rails should be up on the op
f f f f f f f f f f f f f f f f f f f
posite side to ensure that the client does not fall out of bed. Option A can cause client inj
f f f f f f f f f f f f f f f f f f
ury to the skin or joint. Options C and D are useful techniques while turning a client but
f f f f f f f f f f f f f f f f f f
have less priority in terms of safety than use of the bed rails.
f f f f f f f f f f f f
2. The nurse identifies a potential for infection in a client with partial-
f f f f f f f f f f f
thickness (second-degree) and full-thickness (third- f f f f
degree) burns. What intervention has the highest priority in decreasing the client
f f f f f f f f f f f
's risk of infection?f f f
f
A. Administration of plasma expanders
f f f f
f
B. Use of careful handwashing technique
f f f f f
f
C. Application of a topical antibacterial cream
f f f f f f
f
D. Limiting visitors to the client with burns
f f f f f f f
Rationale:
Careful handwashing technique is the single most effective intervention for the prevent
f f f f f f f f f f f
ion of contamination to all clients. Option A reverses the hypovolemia that initially acc
f f f f f f f f f f f f f
ompanies burn trauma but is not related to decreasing the proliferation of infective orga
f f f f f f f f f f f f f
nisms. Options C and D are recommended by various burn centers as possible ways to r
f f f f f f f f f f f f f f f
educe the chance of infection. Option B is a proven technique to prevent infection.
f f f f f f f f f f f f f
3. The nurse is aware that malnutrition is a common problem among clients served
f f f f f f f f f f f f f
by a community health clinic for the homeless. Which laboratory value is the mo
f f f f f f f f f f f f f
st reliable indicator of chronic protein malnutrition?
f f f f f f
,f
A. Low serum albumin level
f f f f
f
B. Low serum transferrin level
f f f f
f
C. High hemoglobin level
f f f
f
D. High cholesterol level
f f f
Rationale:
Long-
term protein deficiency is required to cause significantly lowered serum albumin levels
f f f f f f f f f f f
. Albumin is made by the liver only when adequate amounts of amino acids (from protei
f f f f f f f f f f f f f f f
n breakdown) are available. Albumin has a long half-
f f f f f f f f
life, so acute protein loss does not significantly alter serum levels. Option B is a serum p
f f f f f f f f f f f f f f f f
rotein with a half- f f f
life of only 8 to 10 days, so it will drop with an acute protein deficiency. Options C and
f f f f f f f f f f f f f f f f f f f
D are not clinical measures of protein malnutrition.
f f f f f f f
4. In completing a client's preoperative routine, the nurse finds that the operative pe
f f f f f f f f f f f f
rmit is not signed. The client begins to ask more questions about the surgical proc
f f f f f f f f f f f f f f
edure. Which action should the nurse take next? f f f f f f f
f
A Witness the client's signature to the permit.
f f f f f f f
.
f
B Answer the client's questions about the surgery.
f f f f f f f
.
f
C Inform the surgeon that the operative permit is not signed and the client has questio
f f f f f f f f f f f f f f f
. ns about the surgery. f f f
f
D Reassure the client that the surgeon will answer any questions before the anesthesi
f f f f f f f f f f f f f
. a is administered. f f
Rationale:
The surgeon should be informed immediately that the permit is not signed. It is the surg
f f f f f f f f f f f f f f f
eon's responsibility to explain the procedure to the client and obtain the client's signatur
f f f f f f f f f f f f f
e on the permit. Although the nurse can witness an operative permit, the procedure mus
f f f f f f f f f f f f f f
t first be explained by the health care provider or surgeon, including answering the clien
f f f f f f f f f f f f f f
t's questions. The client's questions should be addressed before the permit is signed.
f f f f f f f f f f f f
, 5. The nurse is assessing several clients prior to surgery. Which factor in a client's h
f f f f f f f f f f f f f f
istory poses the greatest threat for complications to occur during surgery?
f f f f f f f f f f
f
A. Taking birth control pills for the past 2 years
f f f f f f f f f
f
B. Taking anticoagulants for the past year
f f f f f f
f
C. Recently completing antibiotic therapy
f f f f
f
D. Having taken laxatives PRN for the last 6 months
f f f f f f f f f
Rationale:
Anticoagulants increase the risk for bleeding during surgery, which can pose a threat fo f f f f f f f f f f f f f
r the development of surgical complications. The health care provider should be inform
f f f f f f f f f f f f
ed that the client is taking these drugs. Although clients who take birth control pills may
f f f f f f f f f f f f f f f f
be more susceptible to the development of thrombi, such problems usually occur posto
f f f f f f f f f f f f
peratively. A client with option C or D is at less of a surgical risk than with option B.
f f f f f f f f f f f f f f f f f f
6. When assisting a client from the bed to a chair, which procedure is best for the nu
f f f f f f f f f f f f f f f f
rse to follow? f f
f f
A Place the chair parallel to the bed, with its back toward the head of the bed and assist
f f f f f f f f f f f f f f f f f f
. the client in moving to the chair.
f f f f f f
f
B With the nurse's feet spread apart and knees aligned with the client's knees, stand an
f f f f f f f f f f f f f f f
. d pivot the client into the chair.
f f f f f f
f
C Assist the client to a standing position by gently lifting upward, underneath the axill
f f f f f f f f f f f f f f
. ae.
f f
D Stand beside the client, place the client's arms around the nurse's neck, and gently m
f f f f f f f f f f f f f f
. ove the client to the chair. f f f f f
Rationale:
Option B describes the correct positioning of the nurse and affords the nurse a wide bas
f f f f f f f f f f f f f f f
e of support while stabilizing the client's knees when assisting to a standing position. Th
f f f f f f f f f f f f f f
e chair should be placed at a 45-
f f f f f f f
degree angle to the bed, with the back of the chair toward the head of the bed. Clients sh
f f f f f f f f f f f f f f f f f f
ould never be lifted under the axillae; this could damage nerves and strain the nurse's ba
f f f f f f f f f f f f f f f
ck. The client should be instructed to use the arms of the chair and should never place hi
f f f f f f f f f f f f f f f f f
s or her arms around the nurse's neck; this places undue stress on the nurse's neck and ba
f f f f f f f f f f f f f f f f f
ck and increases the risk for a fall.
f f f f f f f
7.Which step(s) should the nurse take when administering ear drops to an adult clien
f f f f f f f f f f f f f
t? (Select all that apply.)
f f f f
, f
A. Place the client in a side-lying position.
f f f f f f f
f
B. Pull the auricle upward and outward.
f f f f f f
f
C. Hold the dropper 6 cm above the ear canal.
f f f f f f f f f
f
D. Place a cotton ball into the inner canal.
f f f f f f f f
f
E. Pull the auricle down and back.
f f f f f f
Rationale:
The correct answers (A and B) are the appropriate administration of ear drops. The drop
f f f f f f f f f f f f f f
per should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed
f f f f f f f f f f f f f f f f f f f
in the outermost canal (D). The auricle is pulled down and back for a child younger than
f f f f f f f f f f f f f f f f f
3 years of age, but not an adult (E).
f f f f f f f f
8.The nurse is instructing a client in the proper use of a metered-
f f f f f f f f f f f f
dose inhaler. Which instruction should the nurse provide the client to ensure the optima
f f f f f f f f f f f f f
l benefits from the drug?
f f f f
f
A. "Fill your lungs with air through your mouth and then compress the inhaler."
f f f f f f f f f f f f f
f
B. "Compress the inhaler while slowly breathing in through your mouth."
f f f f f f f f f f
f
C. "Compress the inhaler while inhaling quickly through your nose."
f f f f f f f f f
f
D. "Exhale completely after compressing the inhaler and then inhale."
f f f f f f f f f
Rationale:
The medication should be inhaled through the mouth simultaneously with compressio
f f f f f f f f f f
n of the inhaler. This will facilitate the desired destination of the aerosol medication dee
f f f f f f f f f f f f f f
p in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow fo
f f f f f f f f f f f f f f f f f
r deep lung penetration
f f f
9. A 20-year-
f f
old female client with a noticeable body odor has refused to shower for the last 3 days. S
f f f f f f f f f f f f f f f f f
he states, "I have been told that it is harmful to bathe during my period." Which action s
f f f f f f f f f f f f f f f f f
hould the nurse take first? f f f f
f
A. Accept and document the client's wish to refrain from bathing.
f f f f f f f f f f
f
B. Offer to give the client a bed bath, avoiding the perineal area.
f f f f f f f f f f f f
f
C. Obtain written brochures about menstruation to give to the client.
f f f f f f f f f f
f
D. Teach the importance of personal hygiene during menstruation with the client.
f f f f f f f f f f f
