HESI Fundamentals Exam Practice Questions with complete solutions

HESI Fundamentals Exam Practice Questions with complete solutions A female nurse who sometimes tries to save time by putting medications in her uniform pocket to deliver to clients, confides that after arriving home she found a hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? A.) Accused of diversion. B.) Reported for stealing. C.) Reported for a HIPAA violation. D.) Accused of unprofessional conduct. A Rationale: Even if this is only one incident, the nurse may be suspected of taking medications on a regular basis and the incident could be interpreted as diversion (A), or diverting narcotics for her own use, which should be reported to the peer review committee and to the State Board of Nursing. (B, C, and D) are also of concern, but (A) is the most serious possible outcome. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? A.) Use distraction techniques during times of spiritual stress and crisis. B.) Reassure the client that his faith will be regained with time and support. C.) Consult with the staff chaplain and ask that the chaplain visit with the client. D.) Use reflective listening techniques when the client expresses spiritual doubts. D Rationale: The most beneficial nursing intervention is to use nonjudgmental reflective listening techniques, to allow the client to feel comfortable expressing his concerns (D). (A and B) are not therapeutic. The client should be consulted before implementing (C). The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A.) Stage 1 pressure sore draining sero-sanguineous drainage. B.) Pressure sore at bony prominence with exudate noted. C.) One-inch pressure sore draining serous fluid. D.) Pressure sore on heel with a small amount of purulent drainage. C Rationale: Serous drainage is clear watery plasma, so (C) provides accurate documentation based on the information provided. Information to stage this pressure score (A) is not provided, and sero-sanguineous drainage is pale and watery with a combination of plasma and red cells, and may be blood-streaked. Exudate (B) is fluid such as pus and serum. Purulent drainage (D) is thick, yellow, green, or brown indicating the presence of dead or living organisms and white blood cells. The nurse is preparing to give a client dehydration IV fluids delivered at a continuous rate of 175 ml/hour. Which infusion device should the nurse use? A.) Portable syringe pump. B.) Cassette infusion pump. C.) Volumetric controller. D.) Nonvolumetric controller. B Rationale: A cassette pump (B) should be used to accurately deliver large volumes of fluid over longer periods of time with extreme precision, such as ml/hour. A syringe pump (A) is accurate for low-dose continuous infusion of low-dose medication at a basal rate, but not large fluid volume replacement. Volumetric (C) and nonvolumetric (D) controllers count drops/minute to administer fluid volume and are inherently inaccurate because of variation in drop size. How should the nurse handle linens that are soiled with incontinent feces? A.) Put the soiled linens in an isolation bag, then place it in the dirty linen hamper. B.) Place an isolation hamper in the client's room and discard the linens in it. C.) Place the soiled linens in a pillow case and deposit them in the dirty linen hamper. D.) Ask the housekeeping staff to pick up the soiled linen from the dirty utility room. C Rationale: The nurse should be careful to keep the soiled linens from contaminating the fresh linens, and should handle the soiled linens like any other dirty linen (C). (A, B, and D) are not indicated. 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. A, B, C, E Rationale: 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. Which technique is most important for the nurse to implement when performing a physical assessment? A.) A head-to-toe approach. B.) The medical systems model. C.) A consistent, systematic approach. D.) An approach related to a nursing model. C Rationale: The most important factor in performing a physical assessment is following a consistent and systematic technique (C) each time an assessment is performed to minimize variation in sequence which may increase the likelihood of omitting a step or exam of an isolated area. The method of completing a physical assessment (A, B, and D) may be at the discretion of the examiner, but a consistent sequence by the examiner provides a reliable method to ensure thorough review of the clients' history, complaints, or body systems. The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? A.) Tossed salad, low-sodium dressing, bacon and tomato sandwich. B.) New England clam chowder, no-salt crackers, fresh fruit salad. C.) Skim milk, turkey salad, roll, and vanilla ice cream. D.) Macaroni and cheese, diet Coke, a slice of cherry pie. C Rationale: Skim milk, turkey, bread, and ice cream, while containing some sodium, are considered low-sodium foods. Bacon, canned soups, especially those with seafood, hard cheeses, macaroni, and most diet drinks are very high in sodium. Which step in the nursing process would involve promoting a safe environment for the client? A.) Planning B.) Diagnosis C.) Assessment D.) Implementation D Rationale: The nurse promotes a safe environment during the implementation stage of the nursing process. During the planning stage, the nurse develops an individualized care plan for the client. The plan contains strategies and alternatives to achieve specific outcomes. During the diagnosis stage, the nurse analyzes the assessment data to determine the health care issues. The nurse collects comprehensive data pertinent to the client's health and situation during the assessment stage. Which healthcare system focuses solely on palliative care? A.) Hospice B.) Rehabilitation C.) Assisted Living D.) Extended care facilities A Rationale: A hospice is a system of family-centered care that allows clients to live and remain at home with comfort, independence, and dignity while easing the pain of terminal illness. The focus of hospice care is palliative care, not curative treatment. Rehabilitation restores a person to his or her fullest physical, mental, social, vocational, and economic potential possible. Assisted living offers an attractive long-term care setting with an environment reminiscent of home and with some resident autonomy. An extended care facility provides intermediate medical, nursing, or custodial care to clients recovering from acute illnesses or clients with chronic illnesses or disabilities. Which statement is applicable to Watson's theory of transpersonal caring? A.) Watson's theory views the client as an adaptive system. B.) Watson's theory is based on stress and the client's reaction to the stressor. C.) Watson's theory focuses on providing the client with culturally specific nursing care. D.) Watson's theory defines the outcome of nursing activity in relation to the humanistic aspects of life. D Rationale: Watson's theory of transpersonal caring defines the outcome of nursing activity in relation to the humanistic aspects of life. The Roy adaptation model views the client as an adaptive system. The Neuman systems model is based on stress and the client's reaction to the stressor. Leininger's theory focuses on cultural diversity; the goal of nursing care should be to provide the client with culturally specific nursing care. Which statement is true about Betty Neuman's theory? A.) Betty Neuman's theory is based on anthropology. B.) Betty Neuman's theory views the client as an adaptive system. C.) Betty Neuman's theory is based on stress and the client's reaction to the stressor. D.) Betty Neuman's theory defines the outcomes of the nursing based on humanistic aspects of life. C Rationale: Betty Neuman's theory is based on stress and the client's reaction to the stressor. In this model, the client is the individual, group, family, or community. The system is composed of five concepts that interact with one another: physiologic, psychologic, sociocultural, developmental, and spiritual. Leininger's theory is based on anthropology. Roy's adaptation model views the client as an adaptive system. Jean Watson's theory of transpersonal caring defines the outcome of the nursing activity with regard to the humanistic aspects of life. A hospital needs to hire a nursing staff for the intensive care of cancer clients. Which of these positions is most likely to be filled by the nurse? A.) Nurse practitioner B.) Nurse administrator C.) Certified nurse-midwife D.) Clinical nurse specialist D Rationale: The hospital will most likely hire a clinical nurse specialist. A clinical nurse specialist is an expert in a specific area of practice and in a particular setting such as an intensive care unit. A nurse practitioner has expertise in taking care of clients in an outpatient, ambulatory care, or community care setting. A nurse administrator looks after the management of the care provided to clients within a health-care agency. A certified nurse-midwife provides care to women during their pregnancy, labor or delivery. Which statement defines "information" gathered by the nurse? A.) It is an individual piece of reality. B.) It is a combination of pieces of reality. C.) It is the organization and interpretation of data. D.) It is the identification of relationship of various data. C Rationale: Information is defined as the organization and interpretation of data or pieces of reality. Datum is an individual piece of reality. When data are combined and relationships among data are identified, the nurse obtains knowledge. A registered nurse is teaching a nursing student about Piaget's theory of cognitive development that includes four periods, which are related to age. Which age group corresponds with concrete operations? A.) 2 to 7 years B.) 7 to 11 years C.) Birth to 2 years D.) 11 years to adulthood B Rationale: According to Piaget's theory of cognitive development, the concrete operations period applies to the age group of 7 to 11 years of age. The preoperational period is during the age group of 2 to 7 years. The sensorimotor period applies to the age group of birth to 2 years. The formal operations period applies to the age group of 11 years to adulthood. What is the primary focus of nursing care in the "family as context" approach? A.) The relationship among family members B.) The health and development of an individual C.) The ability of the family to meet their basic needs D.) The family's process of caregiving for a sick member B Rationale: In the "family as context" approach, the primary focus is the health and development of an individual in a specific environment. The relationship and family processes are the primary focus when the family is viewed as client. When the family is viewed as context, the focus is the ability of the family to meet the basic needs of the individual, not their own needs. The process followed by the family when caring for the sick family member is assessed when family is viewed as client. With reference to the nursing process as a system, what is content? A.) Content is the end product of a system. B.) Content serves to inform a system about how it functions. C.) Content is the product and information obtained from the system. D.) Content is the data or information that comes from a client's assessment. C Rationale: With reference to the nursing process as a system, the content is the product and information obtained from the system. Output is the end product of a system. Feedback serves to inform a system about how it functions. Input is the data or information that comes from a client's assessment. Which of the following statements about a case manager is correct? A.) "A case manager identifies and implements new and more effective approaches to problems." B.) "A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families." C.) "A case manager helps clients identify and clarify health problems and chooses appropriate courses of action to solve these problems." D.) "A case manager applies a critical thinking approach to ensure appropriate, individualized nursing care for specific clients and their families." B Rationale: A case manager has the ability to establish an appropriate care plan based on the assessment of clients and families. A change agent helps identify and implement new and more effective approaches to problems. A counselor helps clients identify and clarify health problems and choose appropriate courses of action. A caregiver applies a critical thinking approach to ensure appropriate, individualized nursing care for clients and their families. Which nursing theory focuses on the client's self-care needs? A.) Roy's theory B.) Orem's theory C.) Watson's theory D.) Leininger's theory B Rationale: Orem's self-care deficit theory focuses on the client's self-care needs. According to Roy's theory, the goal of nursing is to help a person adapt to changes in physiological needs, self-concept, role function, and interdependent relations during health and illness. Watson's theory of transpersonal caring defines the outcome of nursing activity with regards to the humanistic aspects of life. The major concept of Leininger's theory is cultural diversity, with the goal of nursing care being to provide the client with culturally specific nursing care. Which is used for determining the hours of care and staff required for a group of clients? A.) Flow sheets B.) Acuity records C.) Standardized care plans D.) Discharge summary forms B Rationale: An acuity record is used to determine the hours of care and staff required for a given group of clients. A client's acuity level is based on the type and number of nursing interventions. Accurate acuity ratings justify overtime and the number and qualifications of staff needed to safely care for clients. A flow sheet helps to assess data about a client; this data includes vital signs and routine repetitive care. Standardized care plans based on an institution's standards of nursing practice are preprinted and established guidelines used to care for clients who have similar health problems. Discharge documentation includes medications, diet, community resources, follow-up care, and medical contact information in case of an emergency or query. A registered nurse is teaching a nursing student about the concepts that make up a theory. Which point noted by the nursing student needs correction? A.) Concepts consist of interrelated theories. B.) Concepts help describe or label phenomena. C.) Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. D.) Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences. A Rationale: A theory consists of interrelated concepts. Concepts help describe or label phenomena. Concepts that affect the client system are physiological, psychological, sociocultural, developmental or spiritual. Concepts can be simple or complex and relate to an object or event that comes from individual perceptual experiences. Which nursing diagnosis is an example of a client response to a health condition? A.) Risk for acute confusion B.) Impaired social interaction C.) Readiness for enhanced nutrition D.) Readiness for increased family coping B Rationale: Impaired social interaction is an example of a client response to a health condition. Any nursing diagnoses beginning with "risk for" describes human responses to conditions that have not yet occurred, such as Risk for acute confusion. A health promotion nursing diagnosis reflects the clinical judgment that the individual or family client is willing to act to improve their health to prevent the onset of a health condition which has not yet occurred. Readiness for enhanced nutrition and readiness for enhanced family coping are examples of health promotion nursing diagnoses. Which of these refers to the accountability element of the decision making process? A.) Individuals being answerable for their actions B.) Freedom of choice and responsibility for the choices C.) Duties and activities that an individual is employed to perform D.) Authority to give commands and make final decisions specific to a given position A Rationale: Accountability refers to individuals being answerable for their actions. This idea means that a nurse has to accept the commitment to provide excellent client care and the responsibility for the outcomes of the actions. Autonomy refers to the freedom of choice and responsibility of choices. Responsibility refers to the duties and activities that an individual is employed to perform. Authority refers to legitimate power to give commands and make final decisions specific to a given position. Which feature according to Benner is observed in a nurse at the "proficient" level? A.) The nurse learns by means of a set of rules. B.) The nurse identifies the principles of nursing care. C.) The nurse identifies problems related to the health care system. D.) The nurse focuses on managing care rather than managing skills. D Rationale: The nurse at the proficient level has more than 2 or 3 years of experience in the same clinical position. The nurse focuses on managing care rather than managing and performing skills. The novice nurse learns by means of a set of rules, which are usually stepwise and linear. The advanced beginner has observational experience and is able to identify the principles of nursing care. The expert nurse is skilled at identifying client-centered problems, health care system-related problems, and the needs of the novice nurse. In which process of Swanson's theory is the nurse engaging when explaining neonatal care to a parent? A.) Enabling B.) Knowing C.) Doing for D.) Being with A Rationale: According to Swanson's theory, the nurse is engaging in enabling when explaining the care of a neonate to a parent. Enabling includes informing/explaining/supporting/allowing, focusing, generating alternatives, validating, and giving feedback. The process of knowing includes avoiding assumptions, centering on the one being cared for, assessing thoroughly, seeking cues, and engaging the self or both. The process of doing for includes comforting, anticipating, performing skillfully, protecting, and preserving dignity. The process of being with includes being there, conveying ability, sharing feelings, and not burdening. A nurse is teaching a parent about the different temperaments that a child may display. What characteristics does a slow-to-warm up child display? Select all that apply. A.) The child adapts slowly with frequent communication. B.) This child is regular and predictable in his or her habits. C.) The child is highly active, irritable, and irregular in his or her habits. D.) The child reacts with mild but passive resistance to novelty. E.) The child reacts negatively and with mild intensity to new stimuli. A, D, E Rationale: A slow-to-warm up child adapts slowly with frequent communication and reacts to novelty with mild but passive resistance. A slow-to-warm up child also reacts negatively and with mild intensity to new stimuli. An easy child is regular and predictable in his or her habits. A difficult child is highly active, irritable, and irregular in his or her habits. Which of these is a part of health belief model? A.) Behavioral outcomes B.) Behavior-specific knowledge C.) Perception of susceptibility to an illness D.) Individual characteristics and experience C Rationale: The health belief model is divided into three components. The first component is an individual's perception of susceptibility to an illness. The second component is an individual's perception of seriousness of an illness. The third component is the preventive actions taken by a person. The health promotion model focuses on behavioral outcomes, behavior-specific knowledge and affect, and individual characteristics and experience. According to Erikson's theory of psychosocial development, which opposing conflicts is an older adult likely to face? A.) Trust versus Mistrust B.) Integrity versus Despair C.) Intimacy versus Isolation D.) Industry versus Inferiority B Rationale: According to Erikson's theory of psychosocial development, an older adult is likely to face the opposing conflict of Integrity versus Despair. An infant in the age group between birth and one year old is likely to face the opposing conflicts Trust versus Mistrust. A young adult is likely to face the opposing conflicts Intimacy versus Isolation. School-aged children between the ages of 6 and 11 years are likely to face the opposing conflicts Industry versus Inferiority. A nurse is in the process of conducting research. What action indicates that the nurse is designing the study? A.) The nurse gathers all relevant articles and focuses on reviewing the literature. B.) The nurse obtains approval from the proper authorities and enlists the research subjects. C.) The nurse checks whether all investigators are following the appropriate study protocol. D.) The nurse prepares questionnaires and selects the treatment plans necessary for the study. D Rationale: The stage of designing the study is when the nurse chooses the instrumentation for conducting the study. In this stage, the nurse prepares questionnaires and selects physiological measures, interviews, and treatments necessary for the study. The first stage of the research process involves identifying of the problem. At this stage the nurse may gather all relevant articles and review literature for the purpose of conducting the research. The stage of conducting the study involves the nurse obtaining approval from the appropriate authorities and enlisting research subjects. The nurse also monitors whether all investigators are following the appropriate study protocol in order to ensure accuracy of the findings. Which theory details nursing interventions for a specific phenomenon and the expected outcome of care? A.) Grand theories B.) Predictive theories C.) Descriptive theories D.) Prescriptive theories D Rationale: Prescriptive theories detail nursing interventions for a specific phenomenon and the expected outcome of the care. Grand theories provide the structural framework for broad, abstract ideas about nursing. Predictive theories identify conditions or factors that predict a phenomenon. Descriptive theories help to explain client assessments. A registered nurse is teaching a nursing student about Maslow's hierarchy of needs. Which statement made by the nursing student needs correction? A.) "The hierarchy of basic human needs includes five levels of priority." B.) "The second level includes safety and security needs, which involve physical and psychological security." C.) "The fourth level contains love and belonging needs, including friendship, social relationships, and sexual love." D.) "The final level is the need for self-actualization, which includes the ability to solve problems and cope realistically with situations of life." C Rationale: The third level contains love and belonging needs, which includes friendship, social relationships, and sexual love. The fourth level encompasses esteem and self-esteem needs, which involve self-confidence, usefulness, achievement, and self-worth. The hierarchy of basic human needs includes five levels of priority. The second level includes safety and security needs, which involve physical and psychological security. The final level is the need for self-actualization. A client with bone cancer is receiving hospice care at home. The hospice program also provides respite care. What is the purpose of respite care? A.) Assisting the client with meals and personal care B.) Providing short-term relief to the family caregiver C.) Providing skilled nursing interventions for the client D.) Providing counseling and treatment for behavioral problems B Rationale: Hospice programs are focused at providing pain relief to the client. Some hospice programs also provide short-term relief or "time-off" to the family caregiver. This enables the caregiver to leave the home to attend to other activities while the client is looked after by a responsible person. Services in an assisted living facility provide meals and personal care to the clients. A skilled nursing facility or an intermediate care facility provides skilled interventions such as intravenous administration of fluids, wound care, or long-term ventilator management. Psychiatric facilities provide counseling and treatment to clients for behavioral problems. What is a stressor? A.) A stressor is any stimuli that can produce tension and cause instability within the system. B.) A stressor exists within the client system, such as the physiological and behavioral responses to illnesses. C.) A stressor exists outside the client system; external stressors include changes in healthcare policies or increased the crime rates. D.) A stressor is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations. A Rationale: A stressor is any stimuli that can produce tension and cause instability within the system. Internal factors exist within the client system, like the physiological and behavioral responses to illnesses. External factors exist outside the client system; these stressors include changes in healthcare policies or increased crime rates. A phenomenon is a term, description, or label given to describe an idea or responses about an event, a situation, a process, a group of events, or a group of situations. What is the purpose of block and parish nursing? A.) To provide services to older clients B.) To promote health throughout a school curriculum C.) To provide nursing services with a focus on health promotion and education D.) To provide primary care to a client population living in a community A Rationale: In block and parish nursing, nurses living within a neighborhood provide services to older clients or those unable to leave their homes. Health promotion throughout a school curriculum is provided by school health. Nurse-managed clinics provide nursing services with a focus on health promotion and education, chronic disease assessment management, and support for self-care and caregivers. Community health centers are outpatient clinics that provide primary care to a client population living in a community. Which of these cultural groups is known to practice Ayurveda to prevent and treat illness? A.) East Asian B.) Hispanic C.) Asian Indian D.) Native American C Rationale: Asian Indians are known to practice Ayurveda (a healing system comprised of a combination of dietary, herbal, and other naturalistic therapies) to prevent and treat illness. Many East Asians use yin and yang treatment to restore balance. Hispanic groups tend to use a combination of prayers, herbs, and other rituals to treat traditional illnesses. Native Americans are known to rely on a combination of prayers, chanting, and herbs to treat illnesses caused by supernatural, psychological, and physical factors. Which of these is true about SOAP progress note method? A.) The A in SOAP stands for action. B.) The P in SOAP stands for problem. C.) SOAP progress note has a nursing origin. D.) SOAP progress note includes assessment information. D Rationale: SOAP progress notes include assessment information or diagnoses based on data. The A in SOAP stands for assessment and not action. The P stands for plan, not problem. SOAP progress note originate from medical records.