FUNDAMENTAL HESI UPDATED COMPREHENSIVE
EXAMS QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is teaching an adolescent about type 1 diabetes and self-care. Which
questions from the client indicate a need for additional teaching in the cognitive
domain? Select all that apply.
1
"What is diabetes?"
2
"What will my friends think?"
3
"How do I give myself an injection?"
4
"Can you tell me how the glucose monitor works?"
5
"How do I get the insulin from the vial into the syringe? - ✔✔1,4
Acquiring knowledge or understanding aids in developing concepts, rather than skills or
attitudes, and is a basic learning task in the cognitive domain. Values and self-
realization are in the affective domain. Skills acquisition is in the psychomotor domain.
✔✔Place each step of the nursing process in the order that it should be used.
Correct
1.
,Obtain client's nursing history.
Correct
2.
State client's nursing needs.
Correct
3.
Identify goals for care.
Correct
4.
Develop a plan of care.
Correct
5.
Implement nursing interventions. - ✔✔First the nurse should gather data. Based on the
data, the client's needs are assessed. After the needs have been determined, the goals
for care are established. The next step is planning care based on the knowledge gained
from the previous steps. Implementation follows the development of the plan of care.
✔✔In what position should the nurse place a client recovering from general anesthesia?
1
Supine
Correct2
Side-lying
3
High Fowler
4
Trendelenburg - ✔✔2
Turning the client to the side promotes drainage of secretions and prevents aspiration,
especially when the gag reflex is not intact. This position also brings the tongue forward,
preventing it from occluding the airway when it is in the relaxed state. The risk for
aspiration is increased when the supine position is assumed by a semi-alert client. High
Fowler position may cause the neck to flex in a client who is not alert, interfering with
respirations. Trendelenburg position is not used for a postoperative client because it
interferes with breathing.
✔✔Which age-related change should the nurse consider when formulating a plan of
care for an older adult? Select all that apply.
Incorrect 1
Difficulty in swallowing
2
Increased sensitivity to heat
3
Increased sensitivity to glare
4
Diminished sensation of pain
5
Heightened response to stimuli
,. - ✔✔3,4
Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter
contribute to an increased sensitivity to glare. Diminished sensation of pain may make
an older individual unaware of a serious illness, thermal extremes, or excessive
pressure. There should be no interference with swallowing in older individuals. Older
individuals tend to feel the cold and rarely complain of the heat. There is a decreased
response to stimuli in the older individual
✔✔The spouse of a comatose client who has severe internal bleeding refuses to allow
transfusions of whole blood because they are Jehovah's Witnesses. The client does not
have a Durable Power of Attorney for Healthcare. What action should the nurse take?
1
Institute the prescribed blood transfusion because the client's survival depends on
volume replacement.
2
Clarify the reason why the transfusion is necessary and explain the implications if there
is no transfusion.
3
Phone the health care provider for an administrative prescription to give the transfusion
under these circumstances.
4
Give the spouse a treatment refusal form to sign and notify the health care provider that
a court order now can be sought - ✔✔4
The client is unconscious. Although the spouse can give consent, there is no legal
power to refuse a treatment for the client unless previously authorized to do so by a
power of attorney or a health care proxy; the court can make a decision for the client.
Explanations will not be effective at this time and will not meet the client's needs.
Instituting the prescribed blood transfusion and phoning the health care provider for an
administrative prescription are without legal basis, and the nurse may be held liable.
✔✔Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby
out of the hospital. Staff members are unable to contact her health care provider. The
client arrives at the nursery and asks that her infant be given to her to take home. What
is the most appropriate nursing action?
1
Give the infant to the client and instruct her regarding the infant's care.
2
Explain to the client that she can leave, but her infant must remain in the hospital.
3
Emphasize to the client that the infant is a minor and legally must remain until
prescriptions are received.
4
Tell the client that hospital policy prevents the staff from releasing the infant until ready
for discharge - ✔✔1
, When a client signs herself and her infant out of the hospital, she is legally responsible
for her infant. The infant is the responsibility of the mother and can leave with the
mother when she signs them out.
✔✔A client reports fatigue and dyspnea and appears pale. The nurse questions the
client about medications currently being taken. In light of the symptoms, which
medication causes the nurse to be most concerned?
1
Famotidine (Pepcid)
2
Methyldopa (Aldomet)
3
Ferrous sulfate (Feosol)
4
Levothyroxine (Synthroid) - ✔✔Methyldopa is associated with acquired hemolytic
anemia and should be discontinued to prevent progression and complications.
Famotidine will not cause these symptoms; it decreases gastric acid secretion, which
will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement
to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red
blood cell destruction.
✔✔The nurse assesses a client's pulse and documents the strength of the pulse as 3+.
The nurse understands that this indicates the pulse is:
1
faint, barely detectable.
2
slightly weak, palpable.
3
normal.
4
bounding. - ✔✔The strength of a pulse is a measurement of the force at which blood is
ejected against the arterial wall. Palpation should be done using the fingertips and
intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1
+ indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished
pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.
✔✔A toddler screams and cries noisily after parental visits, disturbing all the other
children. When the crying is particularly loud and prolonged, the nurse puts the crib in a
separate room and closes the door. The toddler is left there until the crying ceases, a
matter of 30 or 45 minutes. Legally, how should this behavior be interpreted?
1
Limits had to be set to control the child's crying.
2
The child had a right to remain in the room with the other children.
3
The child had to be removed because the other children needed to be considered.
EXAMS QUESTIONS AND ANSWERS SURE A+
✔✔A nurse is teaching an adolescent about type 1 diabetes and self-care. Which
questions from the client indicate a need for additional teaching in the cognitive
domain? Select all that apply.
1
"What is diabetes?"
2
"What will my friends think?"
3
"How do I give myself an injection?"
4
"Can you tell me how the glucose monitor works?"
5
"How do I get the insulin from the vial into the syringe? - ✔✔1,4
Acquiring knowledge or understanding aids in developing concepts, rather than skills or
attitudes, and is a basic learning task in the cognitive domain. Values and self-
realization are in the affective domain. Skills acquisition is in the psychomotor domain.
✔✔Place each step of the nursing process in the order that it should be used.
Correct
1.
,Obtain client's nursing history.
Correct
2.
State client's nursing needs.
Correct
3.
Identify goals for care.
Correct
4.
Develop a plan of care.
Correct
5.
Implement nursing interventions. - ✔✔First the nurse should gather data. Based on the
data, the client's needs are assessed. After the needs have been determined, the goals
for care are established. The next step is planning care based on the knowledge gained
from the previous steps. Implementation follows the development of the plan of care.
✔✔In what position should the nurse place a client recovering from general anesthesia?
1
Supine
Correct2
Side-lying
3
High Fowler
4
Trendelenburg - ✔✔2
Turning the client to the side promotes drainage of secretions and prevents aspiration,
especially when the gag reflex is not intact. This position also brings the tongue forward,
preventing it from occluding the airway when it is in the relaxed state. The risk for
aspiration is increased when the supine position is assumed by a semi-alert client. High
Fowler position may cause the neck to flex in a client who is not alert, interfering with
respirations. Trendelenburg position is not used for a postoperative client because it
interferes with breathing.
✔✔Which age-related change should the nurse consider when formulating a plan of
care for an older adult? Select all that apply.
Incorrect 1
Difficulty in swallowing
2
Increased sensitivity to heat
3
Increased sensitivity to glare
4
Diminished sensation of pain
5
Heightened response to stimuli
,. - ✔✔3,4
Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter
contribute to an increased sensitivity to glare. Diminished sensation of pain may make
an older individual unaware of a serious illness, thermal extremes, or excessive
pressure. There should be no interference with swallowing in older individuals. Older
individuals tend to feel the cold and rarely complain of the heat. There is a decreased
response to stimuli in the older individual
✔✔The spouse of a comatose client who has severe internal bleeding refuses to allow
transfusions of whole blood because they are Jehovah's Witnesses. The client does not
have a Durable Power of Attorney for Healthcare. What action should the nurse take?
1
Institute the prescribed blood transfusion because the client's survival depends on
volume replacement.
2
Clarify the reason why the transfusion is necessary and explain the implications if there
is no transfusion.
3
Phone the health care provider for an administrative prescription to give the transfusion
under these circumstances.
4
Give the spouse a treatment refusal form to sign and notify the health care provider that
a court order now can be sought - ✔✔4
The client is unconscious. Although the spouse can give consent, there is no legal
power to refuse a treatment for the client unless previously authorized to do so by a
power of attorney or a health care proxy; the court can make a decision for the client.
Explanations will not be effective at this time and will not meet the client's needs.
Instituting the prescribed blood transfusion and phoning the health care provider for an
administrative prescription are without legal basis, and the nurse may be held liable.
✔✔Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby
out of the hospital. Staff members are unable to contact her health care provider. The
client arrives at the nursery and asks that her infant be given to her to take home. What
is the most appropriate nursing action?
1
Give the infant to the client and instruct her regarding the infant's care.
2
Explain to the client that she can leave, but her infant must remain in the hospital.
3
Emphasize to the client that the infant is a minor and legally must remain until
prescriptions are received.
4
Tell the client that hospital policy prevents the staff from releasing the infant until ready
for discharge - ✔✔1
, When a client signs herself and her infant out of the hospital, she is legally responsible
for her infant. The infant is the responsibility of the mother and can leave with the
mother when she signs them out.
✔✔A client reports fatigue and dyspnea and appears pale. The nurse questions the
client about medications currently being taken. In light of the symptoms, which
medication causes the nurse to be most concerned?
1
Famotidine (Pepcid)
2
Methyldopa (Aldomet)
3
Ferrous sulfate (Feosol)
4
Levothyroxine (Synthroid) - ✔✔Methyldopa is associated with acquired hemolytic
anemia and should be discontinued to prevent progression and complications.
Famotidine will not cause these symptoms; it decreases gastric acid secretion, which
will decrease the risk of gastrointestinal bleeding. Ferrous sulfate is an iron supplement
to correct, not cause, symptoms of anemia. Levothyroxine is not associated with red
blood cell destruction.
✔✔The nurse assesses a client's pulse and documents the strength of the pulse as 3+.
The nurse understands that this indicates the pulse is:
1
faint, barely detectable.
2
slightly weak, palpable.
3
normal.
4
bounding. - ✔✔The strength of a pulse is a measurement of the force at which blood is
ejected against the arterial wall. Palpation should be done using the fingertips and
intensity of the pulse graded on a scale of 0 to 4 + with 0 indicating no palpable pulse, 1
+ indicating a faint, but detectable pulse, 2 + suggesting a slightly more diminished
pulse than normal, 3 + is a normal pulse, and 4 + indicating a bounding pulse.
✔✔A toddler screams and cries noisily after parental visits, disturbing all the other
children. When the crying is particularly loud and prolonged, the nurse puts the crib in a
separate room and closes the door. The toddler is left there until the crying ceases, a
matter of 30 or 45 minutes. Legally, how should this behavior be interpreted?
1
Limits had to be set to control the child's crying.
2
The child had a right to remain in the room with the other children.
3
The child had to be removed because the other children needed to be considered.
