HESI Fundamentals Practice Exam

The healthcare provider prescribes the diuretic metolazone 7.5mg PO. Metolazone is available in 5mg tablets. How much should the nurse plan to administer?

1 1/2 tablets

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

While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? A. Acknowledge that she is supporting the arm correctly. B. Encourage her to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct her to grip directly over the joint for better motion.

Acknowledge that she is supporting the arm correctly

A hospitalized male client is receiving nasogastric tube feeding via a small-bore tube and a continuous 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After clearing the tube with 30ml of air, check the pH of fluid withdrawn from the tube.

A client with pneumonia has a decrease in O2Sats 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

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

Closed Ended Questions

The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? A. Thalamus. B. Hypothalamus. C. Frontal lobe. D. Parietal lobe.

Frontal Lobe

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 disorientated to place and time

A nurse is preparing to give meds through an NG tube. Which nursing action should prevent complications during administration?

Mix each medication individually.

The UAPs working on a chronic neuro unit ask the nurse to help then determine the safest way to transfer an elderly client with a left sided weakness from the bed to the chair. What 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.

The nurse observes that a male client has removed the covering form 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 nurse is performing nasotracheal suctioning. After suctioning the clients trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next.

Re-oxygenate the client before attempting to suction again.

The nurse observes an UAP taking a clients blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement.

Reassess the clients BP using a larger cuff

A Sub-Saharan African widowed immigrant woman lives with her deceased husband's brother and his family, which includes the brother-in-law's children and the widow's adult children. EAch family member speaks fluit English. Surgery was recommended for the 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 assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the A. Arms. B. Upper torso. C. Head. D. Feet.

Upper Torso

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

What vitamin and mineral supplements do you take?

Judaism prohibits

Autopsy

On admission, a client presents a signed living will that includes a DNR prescription. When the client stops breathing, the nurse performs CPR and successfully revives the client. What legal issues could be brought against the nurse?

Battery

After completing an assessment and determining that a client has a problem, which action should the nurse perform next? A. Determine the etiology of the problem. B. Prioritize nursing care interventions. C. Plan appropriate interventions. D. Collaborate with the client to set goals.

Determine the etiology of the problem

The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler delivered medication to demonstrate correct use of the inhaler.

During the inhalation

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

Flush the tube with water.

A client is in the radiology department at 0900 when the presciption Lovofloxacin 500mg IV q24hr 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

An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? A. Reaffirm the client's desire for no resuscitative efforts. B. Transfer the client to a hospice inpatient facility. C. Prepare the family for the client's impending death. D. Notify the healthcare provider of the family's request.

Notify the healthcare provider of the family's request.

Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? A. Height in inches or centimeters. B. Weight in kilograms or pounds. C. Triceps skin fold thickness. D. Upper arm circumference.

Upper arm Circumference

The nurse is caring for a client who is receiving 24hr total parenteral nutrition (TPN) via a central line at 54ml/hr. When initially assessing the client, the nurse notes that TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take?

Infuse 10% dextrose and water at 54ml/hr

A healthcare provider prescibes an IV infusion of 1000ml of Riger's Lactate with 30 units of Pitocin to run in over 4hrs for a client who has just delievered a 10lbs infant via cesarean section. The tubing has been changed to a 20gtt/ml administration set. The nurse plans to set the flow rate to how many gtt/min?

83 gtt/min 20gtt/ml x 1000 ml/4hrs x 1hr/60mins = 83gtt/min

The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? A. 80 B. 8 C. 21 D. 25

21

A nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide?

Genetic and Familial Disorders

A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. the nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time?

Initiate an alternate site for the IV infusion of the medication

When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? A. Complimentary healing practices interfere with the efficacy of the medical model of treatment. B. Conventional medications are likely to interact with folk remedies and cause adverse effects. C. Many complimentary healing practices can be used in conjunction with conventional practices. D. Conventional medical practices will ultimately replace the use of complimentary healing practices.

Many complimentary healing practices an be used in conjunction with conventional practices.

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

Rashes in the axillary, groin, and skin fold regions.

An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? A. Position the client on the right side of the bed in reverse Trendelenburg. B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap. C. Reposition in a Sim's position with the client's weight on the anterior ilium. D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Reposition in a Sim's position with the clien'ts weight on the anterior ilium.

A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his would care after discharge?

The client demonstrates the wound care procedure correctly.

An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? A. A nurse who worked the 7 to 3 shift at the hospital and wrote poor nursing notes. B. The nurse assigned to care for the client who was at lunch at the time of the fall. C. The nurse who transferred the client to the chair when the fall occurred. D. The charge nurse who completed rounds 30 minutes before the fall occurred.

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

Buddhism forbids use of

Alcohol in any form

An elderly 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

At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to the client's silence?

It is OK if you don't want to talk about your surgery. I will be available when you are ready

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

Request and document the name of the certified translator

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.

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 client's heart sounds?

Use the stethoscope bell over the valvular areas of the anterior chest.

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

1.5

Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? A. 11,000 units. B. 13,000 units. C. 15,000 units. D. 17,000 units.

11000 units

The nurse mixes 50mg of Niproide in 250ml of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182lbs. Using a drip factor of 60gtt/ml, how many drops permin should the client receive?

124gtt/min lbs to kg 182/2.2 = 82.73kg Dosage for the client 5mcg X 82.73 =413mcg/min mcg / ml 250/50000mcg =200 mcg/ml 2.07ml/min with a drip factor of 60gtt/ml 60 x 2.07 =124.28gtt/min

A client is to receive 10mEq of KCL diluted in 250ml of normal saline over 4hrs. At what rate should the nurse set the clients IV infusion pump?

63ml/hr

A male client is being discharged with a prescription for the bronchodialator 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?

8am 4pm midnight

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

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

Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? A. Apply a condom catheter. B. Apply a skin protectant. C. Encourage increased fluid intake. D. Assess for bladder distention.

Assess for bladder distention.

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 spays, powders, and perfumes.

An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? A. Be sure to have a complete physical examination before beginning your planned exercise program. B. Be careful that the exercise program doesn't simply add to your stress level, making you want to eat more. C. Increased exercise helps to reduce stress, so you may not need to spend money on a stress management class. D. Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation.

Be sure to have a complete physical examination before beginning your planned exercise program.

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

Chest x-ray

Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices.

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

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

Commend the client for selecting a high biologic value protein.

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with KCL 20mEq at 83ml/hr. The client's eight-hr urine output is 400ml, blood urea nitrogen (BUN) is 15mg/dl, lungs are clear bilaterally, serum glucose is 120mg/dl, and serum K is 3.7 mEq/L. Which action is most important for the nurse to implement?

Document in the medical record that these normal findings are expected outcomes

During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? A. Provide additional coffee on the client's breakfast tray. B. Exchange the client's grape juice for cranberry juice. C. Bring the client additional fruit at mid-morning. D. Encourage additional oral intake of juices and water.

Encourage additional oral intake of juices and water.

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

Ensure the accuracy of the blood type match.

An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? A. Prone. B. Fowler's. C. Sims'. D. Supine.

Fowler's

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

Give an around the clock schedule for administration of analgesics.

A resident in a skille dnursing facility for short term rehab 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 into the client's medical record?

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

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 try. Other liquids, including gelatin, Popsicles, and juices , remain untouched. What explanation is most appropriate for this behavior?

Hot remedies restor the balance after surgery, which is considered a cold condition

The nurse is instructing a client with high cholesterol about diet and life style modification. what comment from the client indicated that the teaching has been effective

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

At the beginning of the shift the nurse assesses a client who is admitted from the PACU. When should the nurse document the client's findings?

Immediately after the assessments are completed.

An African-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? A. Inquire about the source and type of pain. B. Examine the nose for congestion and discharge. C. Take vital signs for temperature elevation. D. Explore the abdominal area for distension.

Inquire about the source and type of pain.

What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications

Insert a Huber-point needle into the port.

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

Which action is most important for the nurse to implement when donning sterile gloves? A. Maintain thumb at a ninety degree angle. B. Hold hands with fingers down while gloving. C. Keep gloved hands above the elbows. D. Put the glove on the dominant hand first.

Keep gloved hands above the elbows

examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5cm in diameter. How should the nurse record this finding?

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

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.

A client's infusion of normal saline infiltrated earlier today and approximately 500ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding stronger pain medications. What initial action is most important for the nurse to take?

Measure the pulse volume and capillary refill distal to the infiltration.

When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? A. Establish a new nursing diagnosis. B. Note which actions were not implemented. C. Add additional nursing orders to the plan. D. Collaborate with the healthcare provider to make changes.

Note which actions were not implemented.

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

Nutritional History

In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly

Often follows relocation to new surroundings

A 73 year old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in the client's teaching plan?

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

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.

Skim milk, turkey salad, roll, and vanilla ice cream.

Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? A. That means you have derived the maximum benefit, and the heat can be removed. B. Your blood vessels are becoming dilated and removing the heat from the site. C. We will increase the temperature 5 degrees when the pad no longer feels warm. D. The body's receptors adapt over time as they are exposed to heat.

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

The IV infusion terbutaline sulfate 5mg in 500ml of D5W, infusing at a rate of 30 mcg/min, is prescribed for a client in premature labor. How many ml/hr should the nurse set hte infusion pump?

180

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

A lactating woman nursing her 3 day old infant.

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 client's beliefs?

Blood transfusions are forbidden

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

Continue asking the mother questions about the child.

During the daily nursing assessment, a client begins to cry and states that 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

A nurse assigns a 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

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. What action should the nurse take first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use.

Reposition the client on her side

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? A. Adequate venous blood flow to the lower extremities. B. Estimated amount of body fat by an underarm skinfold. C. Degree of flexion and extension of the client's knee joint. D. Change in the circumference of the joint in centimeters.

Degree of flexion and extension of the client's knee joint.

The healthcare provider prescribes furosemide (Lasix) 15mg IV stat. On hand is Lasix 20 mg/2ml. How many milliliters should the nurse administer.

1.5ml