HESI (Fundamentals 1st Semester)

The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior?

"Hot" remedies restore balance after surgery, which is considered a "cold" condition.

A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement?

Ensure the accuracy of the blood type match

Which assessment data provides the most accurate determination of proper placement of nasogastric tube?

Examining chest x-ray obtained after the tubing was inserted

An older client had a hemiarthroplasty of the left hip yesterfay due to the fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this teaching plan?

Place a pillow between your knees while laying in bed to prevent hip dislocation

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?

Assess for bladder distention

A clients daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additional tablets should the nurse administer so the client receives the total newly prescribed dose for the day?

1

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How many tablets should the nurse plan to administer?

1 1/2 tablets

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination?

Provide warm prune juice before the client goes to bed at night

Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer?

1.5

The nurse observes an unlicensed personnel (UAP) checking a clients blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the clients usual range. Which action is most important for the nurse to implement?

Reassess the clients blood pressure using a larger cuff

A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125 mg clavulanate tablets. How many tablets should the nurse administer for each dose?

2

A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse adminster?

2

The nurse is instructing a client with high cholesterol about diet and lifestyle modification. What comment from the client indicates that the teaching has been effective?

"I will limit my intake of beef to 4 ounces per week"

A male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual medication instead. What should be the nurses first response?

"It is important that you continue your medication while learning to meditate"

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What the best response by the nurse?

"The body's receptors adapt over time as they are exposed to heat"

A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment?

"What vitamin and mineral supplements do you take?"

A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first?

Assist the ambulating client back to the bed

A client is receiving alprazolam (Xanax) 0.75 mg PO bid for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many tablets should the nurse administer?

1.5

On admission, a client present a signed living will that includes a Do Not Resuscitate (DNR_) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse?

Battery

A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?

8 am, 4 pm, and midnight

Which technique is most important for the nurse to implement when performing a physical assessment?

A consistent, systematic approach

What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?

A decreased flow rate could result in the formation of a thrombosis

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

A lactating women nursing her 3 day old infant

A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube

Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met?

Accepts that punishment from God is not related to illness

A male client with acquired immunodeficiency syndrome (ADIS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?

Ask the client if this decision has been discussed with his healthcare provider

A clients spouse is learning passive range of motion for the clients contracted shoulder. The nurse observes that the spouse is holding the clients arm above and below the elbow. Which nursing action should the nurse implement?

Acknowledge that the spouse is supporting the arm correctly

The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan?

Avoid any types of sprays, powders, and perfumes

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the clients beliefs?

Blood transfusions are forbidden

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?

Check capillary refill of toes on lower extremity with Unna's paste boot

During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure?

Degree of flexion and extension of the clients knee joint

Which snack food is best for the nurse to provide a client with myastenia gravis who is at risk for altered nutritional status?

Chocolate pudding

The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment?

Client

During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a clients primary health problem?

Closed-ended questions

A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take?

Commend the client for selecting a high biologic value protein

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings?

Complains of inability to empty bladder.

The nurse notices that the mother of a 9 year old Vietnamese child always looks at the floor when she talks the nurse. What action should the nurse take?

Continue asking the mother questions about the child

The nurse is providing passive range of motion (ROM) exercises to the hip and knee with one hand, what action should the nurse take next?

Cradle the clients heel

A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the clients readiness to manage wound care after discharge?

Demonstrating the wound care procedure correctly

After completing an assessment and determining that a client has a problem, which action should the nurse perform next?

Determine the etiology of the problem

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate?

Disorientation often followes a relocation to new surroundings

When making the bed of a client who needs a bed cradle, which action should the nurse include?

Drape the top sheet and covers loosely over the bed cradle

The nurse is preparing to irrigate a clients indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves?

Draw up the irrigating solution into the syringe

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demostrate correcct use of the inhaler?

During the inhalation

The nurse formulates the nursing diagnosis of, "Ineffective health maintenance related to lack of motivation" for a client with Type 2 Diabetes. Which finding supports this nursing diagnosis?

Eats anything and does not think diet makes a difference with health

During intial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement?

Encourage additional oral intake of juices and water

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 clients care?

Fluid volume imbalance

When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement?

Flush the lumen with the saline solution and administer the medication through the lumen

The nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next?

Flush the tube with water

An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings?

Fowlers

The nurse is completing a mental assessment for a client who is demonstrating slow though processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions?

Frontal lobe

A middle-aged woman who enjoys being a teacher and mentor feels that she pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what development stage?

Generativity

An older client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?

Gently lift the client when moving into a desired position

A client who is in hospice care reports increasing amounts of pain. The healthcare prescribes an analgesic every four hours prn. Which action should the nurse implement?

Give an around-the-clock schedule for administration of analgesics

A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?

Give the missed dose at 1300 and change the schedule to administer daily at 1300

A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record?

Healthcare provider notified of client's refusal to have blood specimens collected for testing

A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements?

Herbs should be obtained from manufacturers with a history of quality control of their supplements

A male client with venous incompetence stands up and his blood pressure subsequently drops. Which findings should the nurse identify as a compensatory response?

Increase in pulse rate

Which statement is an example of a correctly written nursing diagnosis statement?

Ineffective coping related to response to positive biopsy test results

The nurse is using a genogram while conducting a clients health assessment and past medical history. What information should the genogram provide?

Inherited familial health disorders

An Africian-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries". Based on this statement, which focused assessment should the nurse conduct?

Inquire about the source and type of pain

Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?

Instruct the client that the stoma will become smaller when the initial swelling diminishes

While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement?

Instruct the client to take slow deep breaths and stop bearing down

A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate?

Is disoriented to place and time

Which action is most important for the nurse to implement when donning sterile gloves?

Keep gloved hands above the elbows

During the daily nursing assessment, a client beings to cry and states the majority of family and friends have stopped calling and visiting. What action should the nurse take?

Listen and show interest as the client expresses these feelings

The nurse is examining a male client who reports itching on his right arm. The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this findings?

Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

When teaching a female client to perform intermittent self-catheterization, the nurse should ensure the clients ability to perform which action?

Locate the perineum

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

Loosen the right wrist restraint

When conducting an admission assessment, the nurse should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practice?

Many complementary healing practices can be used in conjunction with conventional practices

A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration?

Mix each medication individually

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?

Observe the appearance of the skin under the ice pack

The unlicensed assistive personnel working on a chronic neuro unit asks the nurse to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client?

Move the chair parallel to the right side of the bed, and stand the client on the right foot.

When evaluating a clients plan of care, the nurse determines that a desired outcome was not achieved. Which action should the nurse implement first?

Note which actions were not implemented

An older resident at a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that DNR, and the family request hospice care. What action should the nurse implement first?

Notify the healthcare provider of the familys request

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first?

Nutritional history

How should the nurse handle linens that are soiled with incontinent feces?

Place the soiled linens in a pillow case and deposit them in the dirty linen hamper

An older client who is a resident in a long term care facility has been bedridden for a week. Which findings should the nurse identify as a client risk factor for pressure ulcers?

Rashes in the axillary, groin, and skin fold regions

The nurse determines a client's IV solution is infusing at 250 ml/hr. The prescribed rate is 125 ml/hr. What action should the nurse take first?

Slow the IV infusion to keep vein open rate

While caring for a child and mother from Cambodia, what action should the nurse implement to accomodate the clients cultural needs?

Speak initially with the oldest family member to show respect

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What actions should the nurse implement next?

Re-oxygenate the client before attempting to suction again.

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?

Refuse to perform the task that is beyond the nurse's experience

The nurse assigns an unlicensed assistive personnel (UAP) to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP?

Report the results of the vital signs to the nurse

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instructions should the nurse provide the UAP?

Reposition in a Sims position with the clients weight on the anterior ilium

A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. Which action should the nurse take first?

Reposition the client on her side

The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first?

Reposition the clients arm

A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take?

Request and document the name of the certified translator

Which client assessment data is most important for the nurse to consider before ambulating a postoperative client?

Respiratory rate

A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicates the clients protein status for the longest length of time?

Serum albumin

The nurse is evaluating a client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions?

Skim milk, turkey salad, roll, vanilla ice cream

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brothers-in-law children and the widow's adult children. Each family member speaks fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client?

Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse?

The clamp on the urinary drainage bag is open

The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility?

The client voluntarily signed the form

An older client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgement.

The nurse who transferred the client to the chair when the fall occured.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent?

Upper arm circumference

The nurse is assisting an 82 year old client to ambulate. Which is the center of gravity for an elderly person?

Upper torso

During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the clients heart sounds?

Use the stethoscopes bell over the valvular areas of the anterior chest

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first?

Wet to moist dressing

To obtain the most complete assessment data for a client with chronic pain, which information should the nurse obtain?

Which activities during a routine day are impacted by your pain?

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?

Witness the clients signature on the consent form