HESI NEXT GEN PRACTICE - FUNDAMENTALS OF
NURSING QUESTIONS AND ANSWERS
Which action would the nurse take for a client whose right radial pulse is weak and
thready? Select all that apply.
-Assess all peripheral pulses
-Administer intravenous fluids
-Assess and compare both radial pulses
-Ask a second nurse to assess the client's pulses
-Assess the client's pulse oxygenation (SpO2) on that hand
-Assess for edema or other issues that may be restricting peripheral blood flow
-Observe for pallor/skin temperature differences distal to the weak pulse
-Withhold prescribed antihypertensive medications - Answers :-Assess all peripheral
pulses
-Assess and compare both radial pulses
-Ask a second nurse to assess the client's pulses
-Assess for edema or other issues that may be restricting peripheral blood flow
-Observe for pallor/skin temperature differences distal to the weak pulse
**The nurse should not administer IV fluids without a provider's order. The SpO2 may
not be accurate if measured in an area of impaired circulation and should be assessed
on the opposite hand. In this situation the nurse should notify the provider who may
subsequently order specific medications, including antihypertensives, to be withheld, but
the nurse would not do this without appropriate orders.
A client who is positive for human immunodeficiency virus (HIV) is admitted to a surgical
unit after an orthopedic procedure. Select the 2 possible routes of HIV transmission.
-Feces
-Blood
-Semen
-Urine
-Sweat
-Tears - Answers :-Blood
-Semen
**HIV, which is the virus that causes acquired immunodeficiency syndrome (AIDS) is
transmitted through infected blood, semen, and bloody bodily fluids. HIV is not spread
casually. Although HIV may be found in other bodily secretions, including feces, urine,
, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient
enough to be transmitted.
Which finding would the nurse identify as normal for a newborn? Select all that apply.
One, some, or all responses may be correct.
-Flat abdomen
-Corner of the mouth drops with crying
-Baby's weight is 6 lbs (2700 g)
-Copious watery discharge from eyes
-Hands and feet appear cyanosed
-Head circumference of 33 cm (13 inches)
-Does not blink in the presence of light
-Nipples spaced widely apart - Answers :-Baby's weight is 6 lbs (2700 g)
-Hands and feet appear cyanosed
-Head circumference of 33 cm (13 inches)
**The average newborn weighs between 6 and 9 pounds (2700 and 4000 g). The hands
and feet of the newborn are usually cyanosed during the first 24 hours after birth. The
average newborn has a head circumference of 33 to 35 cm (13-14 inches).
**Newborns generally have protuberant (not flat) abdomens. The corner of the mouth
dropping with crying is a sign of facial nerve paralysis that may have been caused
during birth. Copious watery discharge which progresses to purulent is a sign of
Chlamydia conjunctivitis and must be treated immediately. Newborns exhibit a blinking
reflex when light is directed toward the eye. Widely spaced nipples, along with
lymphedema and excessive nuchal tissue, are signs of Turner syndrome.
Which intervention would the nurse perform while caring for an actively dying client?
Select all that apply.
-Admit the client in hospice care.
-Ensure the nurse talks to and not about the client.
-Perform aggressive laboratory tests.
-Provide client and family reassurance.
-Keep the client undisturbed for a long time.
-Try to set a comfortable environment in the room.
-Perform symptom management for the client.
-Encourage family to talk to the client. - Answers :-Ensure the nurse talks to and not
about the client.
-Provide client and family reassurance.
-Try to set a comfortable environment in the room.
NURSING QUESTIONS AND ANSWERS
Which action would the nurse take for a client whose right radial pulse is weak and
thready? Select all that apply.
-Assess all peripheral pulses
-Administer intravenous fluids
-Assess and compare both radial pulses
-Ask a second nurse to assess the client's pulses
-Assess the client's pulse oxygenation (SpO2) on that hand
-Assess for edema or other issues that may be restricting peripheral blood flow
-Observe for pallor/skin temperature differences distal to the weak pulse
-Withhold prescribed antihypertensive medications - Answers :-Assess all peripheral
pulses
-Assess and compare both radial pulses
-Ask a second nurse to assess the client's pulses
-Assess for edema or other issues that may be restricting peripheral blood flow
-Observe for pallor/skin temperature differences distal to the weak pulse
**The nurse should not administer IV fluids without a provider's order. The SpO2 may
not be accurate if measured in an area of impaired circulation and should be assessed
on the opposite hand. In this situation the nurse should notify the provider who may
subsequently order specific medications, including antihypertensives, to be withheld, but
the nurse would not do this without appropriate orders.
A client who is positive for human immunodeficiency virus (HIV) is admitted to a surgical
unit after an orthopedic procedure. Select the 2 possible routes of HIV transmission.
-Feces
-Blood
-Semen
-Urine
-Sweat
-Tears - Answers :-Blood
-Semen
**HIV, which is the virus that causes acquired immunodeficiency syndrome (AIDS) is
transmitted through infected blood, semen, and bloody bodily fluids. HIV is not spread
casually. Although HIV may be found in other bodily secretions, including feces, urine,
, sweat, tears, saliva, sputum, and emesis, the amount of virus is likely not sufficient
enough to be transmitted.
Which finding would the nurse identify as normal for a newborn? Select all that apply.
One, some, or all responses may be correct.
-Flat abdomen
-Corner of the mouth drops with crying
-Baby's weight is 6 lbs (2700 g)
-Copious watery discharge from eyes
-Hands and feet appear cyanosed
-Head circumference of 33 cm (13 inches)
-Does not blink in the presence of light
-Nipples spaced widely apart - Answers :-Baby's weight is 6 lbs (2700 g)
-Hands and feet appear cyanosed
-Head circumference of 33 cm (13 inches)
**The average newborn weighs between 6 and 9 pounds (2700 and 4000 g). The hands
and feet of the newborn are usually cyanosed during the first 24 hours after birth. The
average newborn has a head circumference of 33 to 35 cm (13-14 inches).
**Newborns generally have protuberant (not flat) abdomens. The corner of the mouth
dropping with crying is a sign of facial nerve paralysis that may have been caused
during birth. Copious watery discharge which progresses to purulent is a sign of
Chlamydia conjunctivitis and must be treated immediately. Newborns exhibit a blinking
reflex when light is directed toward the eye. Widely spaced nipples, along with
lymphedema and excessive nuchal tissue, are signs of Turner syndrome.
Which intervention would the nurse perform while caring for an actively dying client?
Select all that apply.
-Admit the client in hospice care.
-Ensure the nurse talks to and not about the client.
-Perform aggressive laboratory tests.
-Provide client and family reassurance.
-Keep the client undisturbed for a long time.
-Try to set a comfortable environment in the room.
-Perform symptom management for the client.
-Encourage family to talk to the client. - Answers :-Ensure the nurse talks to and not
about the client.
-Provide client and family reassurance.
-Try to set a comfortable environment in the room.
