HESI Fundamentals Practice Set 3
A nurse is preparing to insert an IV catheter into a client's arm prior to initiating IV fluid therapy. Which of the following interventions should the nurse implement to prevent infection? a) Thread the IV catheter so that the hub rests at the insertion site b) Shave excess hair from around the insertion site c) Cleanse the site with hydrogen peroxide before IV catheter insertion d) Palpate the site carefully just before inserting the IV catheter
A Inserting the catheter up to the hub reduces the risk of contaminating along the length of the catheter
Which of the following should indicate to a nurse the need to suction a client's tracheostomy? a) irritability b) hypotension c) flushing d) bradycardia
A Irritability is a sign that indicates the client has decreased oxygen to the tissues and the nurse should suction the tracheostomy
A nurse is providing teaching to a client who is recieving chemotherapy. Which of the following client statements indicates an understanding of the teaching? a) "I will disinfect my toothbrush weekly" b) "I will eat fresh fruit for breakfast" c) "I can take a plane to visit my grandson" d) "I can shower up to three times a week"
A The client is encouraged to clean his toothbrush to reduce the risk of oral infection
A nurse is caring for a client who is scheduled to be transferred to a long-term care facility. The client's family questions the nurse about the reasons for the transfer. Which of the following reposnses made by the nurse is apporpriate? a) "The transfer for your family member is being done because it's in his best interest" b) "Have a seat and let me tell you what has happened" c) "Why are you so concerned about the transfer?" d) "I know how you feel. My father had to be sent to a long-term care facility"
B
A nurse is planning to care for a client who has dysphagia following a stroke. The nurse should initiate a referral for which of the following therapies? a) physical therapy b) speech therapy c) occupational therapy d) respiratory therapy
B
Which of the following precautions is important to take when a nurse is caring for a client who has diarrhea due to Shingella? a) have the client wear a mask when receiving visitors b) wash hands before and after client contact c) assign the client to a room with negative pressure air flow d) instruct all visitors to limit time with the client
B
A nurse is caring for a client for whom a nasogatric tube is ordered for stomach decompression. Which of the following actions is appropriate when inserting an NG tube? a) position the client with the head of the bed elevated to 30 degrees prior to insertion of the NG tube b) remove the NG tube if the client begins to gag or choke c) apply suction to the NG tube prior to insertion d) have the client take sips of water to promote insertion of the NG tube into the esophagus
D
A nurse is planning to delegate client care to an assistive personnel. Which of the following factors is most important for the nurse to consider before delegating care? a) the AP's previous trainging b) other tasks assigned to the AP c) the amount of supervision the AP requires d) the facility's jobb description for the AP
D
A nurse is preparing a change-of-shift report. Which of the following is an appropriate method to communicate continuity of care? a) critical pathways b) transfer document c) SBAR d) medication administration record (MAR)
C
A nurse on an oncology unit is caring for a client who has tears in his eyes and states, "The doctor just told me that I don't have long to live." Which of the following is an appropriate response by the nurse? a) I'm suure that you will feel better soon b) chemotherapy is almost always effective c) tell me more about how you're feeling d) we will do our best to keep you as comfortable as possible
C *the nurse is using an open-ended question to allow the client to expand his concerns the last statement is dismissive and doesn't encourage the client to discuss his feelings
A nurse is caring for a client who has an NG tube that is to be irrigated every 8 hr. Which of the following should be used to irrigate the tube in order to maintain fluid and electrolyte balance? a) tap water b) sterile water c) 0.9% sodium chloride d) 0.45% sodium chloride
C 0.9% sodium chloride is an isotonic solution that would be least likely to cause electrolyte imbalace
A nurse is reinforcing teaching regarding the use of a cane to a client who has left-leg weakness. Which of the following should the nurse include in the teaching? a) use the cane on the weak side of the body b) advance the cane and the atrong leg simultaneously c) maintain two points of support on the floor d) advance the cane 30 to 45 cm (12-18 in) with each step
C *the client should have two points of support, the cane and the one foot or both feet on the floor at all times -advance cane 15 to 25 cm at a time (6 to 10 inches) -advance cane while balancing weight on both legs -use cane on STRONGER side of body for support and balance
A nurse is transcribing new prescriptions for a client. Which of the following prescriptions is accurately transcribed by the nurse? a) digoxin 0.25 mg PO q.d. b) NPH insulin 3 units sub q daily before breakfast c) Zolpidem 5 mg PO qhs for sleep d) morphine 4 mg IV bolus every 2 hr. PRN for incisional pain
D -nurse should not use q.d. because it is an error-prone abbreviation -nurse should not use sub q or SQ or qhs because these are all error-prone abbreviations
A nurse is obtaining the health history from a client who has hearing loss. Which of the following actions by the nurse is appropriate? a) speak loudly with the mouth close to the clients ear b) rephrase rather than repeat misunderstood information c) ask a family member about the clients health history d) use a high tone of voice instead of a low tone of voice
B *rephrasing presents information in a new way to promote understanding
A nurse on an oncology unit is caring for a client who has tears in his eyes and states "The doctor just told me that I don't have long to live." Which of the following is an appropriate response of the nurse? a) "I'm sure that you will feel better soon" b) "Chemotherapy is almost always effective" c) "Tell me more about how you're feeling" d) "We will do our best to keep you as comfortable as possible"
C
A nurse is caring for a client who needs a 24-hr urine collection initiated. Which of the following client statements indicates an understanding of the procedure? a) "I had a bowel movement, but I was able to save the urine" b) "I have a specimen in the bathroom from about 30 minutes ago" c) "I flushed what I urinated at 7 am and have saved the rest since" d) "I drink a lot, so I will fill up the bottle and complete the test quickly"
C -for 24 hour urine collection, the client should discard the first voiding and save all subsequent voidings
A nurse is caring for a client who is having difficulty voiding following the removal in an indwelling urinary catheter. Which of the following interventions should the nurse take? a) assess for bladder distention after 6 hr b) encourage the client to use a bed pan in the supine position c) restrict the clients intake of oral fluids d) pour warm water over the clients perineum
D
A nurse is caring for a client who reports pain. When documenting the quality of the client's pain on an initial pain assessment, the nurse should record which of the following client statements? a) "I am having mild pain" b) "The pain makes me feel nauseous" c) "I notice that the pain gets worse after I eat" d) "The pain is like a dull ache in my stomach"
D
A nurse is caring for a client who is refusing a scheduled blood transfusion for religious reasons. The client's partner wants the client to have the blood transfusion. Which of the following actions should the nurse take? a) ask the client to consider a direct donation b) ask the client's family to intervene c) request a consultation with the ethics committee d) withhold the scheduled blood transfusion
D The principle of autonomy ensures a client who is competent the right to refuse treatment
A charge nurse is discussing the responsibility of nurses carig for clients who have C. difficile. Which of the following information should the nurse include in the teaching? a) Assign the client to a room with a negative air-flow system b) Use alcohol-based hand sanitizer when leaving the clients room c) clean contaminated surfaces in the clients room with a phenol solution d) have family members wear a gown and gloves when visiting
D *nurses are responsible for ensuring family members wear gown and gloves to prevent transmission of C. difficile spores -phenol solution does not kill C. difficile spores -nurse should use soap and water b/c alcohol hand sanitizer does not kill C. difficle spores -negative air-flow room not necessary
A nurse is performing a peripheral vascular assessment for a client. When placing the stethoscope on the client's neck, she hears the following sound. This sound indicates which of the following?
***Narrowed arterial lumen -arterial bruits are "blowing" sounds resulting from blood flowing through occluded or narrowed arteries -blood flow through distended jugular veins does not produce a sound
what can increase the risk for infection at an iv site? What is used to clean the site?
-shaving excess hair around insertion site -palpating the site after cleansing b/c this can introduce micro-organisms -iodine or chlorhexidine to cleanse the agent before insertion
If nurse no longer palpates the pulse at 90 mm Hg when inflating the blood pressure cuff, when should the nurse stop inflating the cuff?
-when it gets reaches 30 mm Hg more *in this case 120 mm Hg
A nurse is caring for a client with an order for 5 units of Regular insulin and 10 units of NPH insulin to be mixed together and administered subcutaneously. List the correct order of steps for this procedure.
1) Inject 10 units of air into the bottle of NPH insulin without touching the solution in order to withdraw the desired amount of medication later. The nurse should next inject air into the vial of Regular insulin. 3) The nurse should withdraw the correct dose of Regular insulin from the bottle. 4) Withdraw the correct dose of NPH insulin from the bottle -prevent contamination of the Regular insulin with the NPH insulin
A nurse is preparing to transfer a client from the bed to the stretcher using a slide board. Which of the following actions should the nurse take? a) lower the head of the bed b) instruct the client to place both arms down by his sides c)position the bed slightly lower than the stretcher d) remind the client to extend his neck during transfer
A
The nurse is evaluating a client who has right leg weakness and is learning to use a rubber-tipped standard walker. Which of the following actions by the client indicates proper use of the walker? a) Uses a lifting motion to move the walker b) uses the walker to pull himself up to stand c) takes a step while moving the walker forward d) locks elbows when stepping forward
A
A nurse is providing teaching to a client about techniques to promote sleep. Which of the following instructions should the nurse include in the teaching? a) Consume a light snack of carbohydrates at bedtime b) Drink warm tea at bedtime c) watch TV in bed util drowsy d) exercise 1 hr before bedtime
A -limit intake of fluids before bed to avoid nighttime voiding -limit stimulating activities while in bed such as watching tv -limit exercise before bed
A nurse in a long-term care facility notes that a client coughs frequently during meals and suspects dysphagia. The nurse should assess the client for which of the following behavioral signs of dysphagia? a) storing food in the mouth b) sipping warm liquids c) chewing excessively d) refusing soft foods
A Clients who have dysphagia tend to have incomplete emptying of the food from their mouth. This can lead to collections of food or "pockets" of food left in the mouth, which they tuck in front of the buccal surfaces of the gums
A nurse is reviewing the medical records of a client who has a pressure ulcer. Which of the following is an expected finding? a) serum albumin level of 3 g/dL b) HDL level of 90 mg/dL c) Norton scale score of 18 d) Braden scale score of 20
A Serum albumin level below 3 g/dL indicates protein deficiency, putting the client at risk for pressure ulcer formation and poor wound healing -Braden scale score under 18 indicates pressure ulcer risk -Norton scale score of 16 or less indicates pressure ulcer risk
A nurse is caring for a client receiving IV fluids. During a routine check, the nurse determines that the client has developed phlebitis and removes the IV catheter. Which of the following actions should the nurse take next? a) place a warm compress over the IV site b) record the findings in the client's chart c) notify the client's primary care provider d) prepare to insert a new IV catheter
A The greatest risk to the client is further injury. The next action should take is to apply a warm compress over the IV site to decrease edema and client discomfort.
A nurse is implementing a plan of care for a client who is at risk for falls. Which of the following is an appropriate nursing action? a) implement a regular toileting schedule b) encourage the client to wear athletic socks when ambulating c) place all 4 bed rails in the upright position c) require a family member to remain at the bedside
A The nurse should toilet every 1 to 3 hours to reduce the risk of falls due to the client ambulating to the bathroom without assistance -the nurse can place the two upper rails in an upright position to assist the client in sitting up, however, the nurse should avoid maintaining all 4 rails in the upright position
A nurse is caring for a client who has dementia. Which of the following interventions should the nurse take to minimize the risk for injury for this client? a) use a bed exit alarm system b) raise 4 side rails while client is in bed c) apply one soft wrist restraint d) dim the lights in the client's room
A *a bed alarm system will alert staff members that the client is exiting the bed, therefore this is an appropriate intervention -physical restraints aren't okay for this patient -dimming lights can reduce vision and increase risk for injury
A nurse is caring for a client who has tuberculosis. Which of the following actions should the nurse take? SATA a) Place the client in a negative pressure room b) wear gloves when assisting the client with oral care c) limit each visitor to 2 hr increments d) wear a surgical mask when providing care e) Use antimicrobial sanitizer for hand hygiene
A, B, E -limiting visitors is not necessary -N95 respirator mask should be worn to meet the requirements of airborne precautions
A nurse is providing discharge teaching for a client who has a new prescription for a home oxygen concentrator. Which of the following instructions should the nurse give to the client and his family? SATA a) Check the cord routinely for frays and tearing b) keep the unit at least 4 feet away from a heat source c) Consider purchasing a generator for power backup d) monitor for signs of hypoxia e) Select clothing and bedding made of synthetic materials
A, C, D
A nurse is performing assessments on clients of various ages. Which of the following is an appropriate physical assessment technique? a) Use of a standardized numeric pain rating scale for assessment of a 4 year old's postoperative pain b) measurement of an adult's blood pressure with a cuff whose bladder surrounds 80% of the client's arm circumference c) placement of a stethoscope at the second intercostal space left of the sternum in order to count an infant's apical heart rate d) palpating an older adult client's abdomen before auscultating bowel sounds
B
A nurse is transcribing new orders for insulin based on client's blood glucose readings. The nurse notes that the provider did not write the frequency for checking blood glucose levels on the order sheet. Which of the following is the appropriate action by the nurse? a) Follow the agency policy for routine blood glucose checks b) call the health care provider to determine the frequency of blood glucose checks c) place a note in the client's chart for the provider to review the order the next day d) contact the pharmacist to determine the frequency of blood glucose checks
B
A nurse is reviewing a protocol in preparation for suctioning a client who has a new tracheostomy. Which of the following is an appropriate action for the nurse to take? a) use a resuscitation bag with 80% oxygen prior to the procedure b) select a suction catheter that is half the size of the lumen c) place the end of the suction catheter in water soluble lubricant d) adjust the wall suction apparatus to a pressure of 170 mmHg
B The nurse should select a suction catheter half the size of the lumen to prevent hypoxemia and trauma to the mucosa
A nurse is preparing to administer meperidine (Demerol) 80 mg IM from a 100 mg prefilled syringe. After the injection, which of the following is an appropriate action by the nurse? a) Return the unused portion to the pharmacy b) Have another nurse witness the disposal of the excess medication c) Place the syringe with the unused portion in a locked medication drawer d)Discard the unused medication in the sharps container
B meperidine is a controlled substance -the remaining medication should be wasted with the witness of another nurse
Which of the following techniques should the nurse use when performing nasotracheal suctioning for a client? a) insert the suction catheter while the client is swallowing b) apply intermittent suction when withdrawing the catheter c) place the catheter in a location that is clean and dry for later use d) hold the suction catheter with the clean, non-dominant hand
B *apply intermittent suction during the withdrawal of the catheter to prevent injury to the mucosa. Suctioning continuously for more than 10 seconds can cause cardiopulmonary compromise -the nurse should discard the suction catheter after use to eliminate the risk of reintroducing pathogens into the respiratory tract -hold suction catheter with dominant hand -insert catheter while client is inhaling to prevent inserting the catheter into the esophagus
A nurse is caring for a client who has left-sided paralysis after a cerebrovascular accident. The client is unable to bear down his own weight. Which of the following actions is an appropriate method to move the client from his bed to wheelchair? a) Use a draw sheet and have two assistive personel help move the client b) use a hydraulic life and have an AP help move the client c) obtain a transfer belt and have two AP help move the client d) help the client stand and then pivot to the wheelchair with assistance of the AP
B *safest ergodynamic method of moving the client from the bed to the wheelchair is using a hydraulic device (requires 2 staff members)
A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse recognize as infiltration? a) purulent exudate b) warmth c) skin blanching d) bleeding
C
A nurse is caring for a client who has a prescription for wound irrigation. Which of the following actions should the nurse take? a) wear sterile gloves when removing the old dressing b) warm the irrigation solution to 40.5C (105F) c) cleanse the wound from the center outwards d) use a 20 mL syringe to irrigate the wound
C
A nurse planning care of an adolescent who is postoperative following a lumbar laminectomy. Which of the following interventions should the nurse include in the plan of care? a) limit the adolescent's visitors b) select the adolescent's food choices c)allow the adolescent to make decisions regarding the daily routine d) encourage the adolescent's parents to assist with personal hygiene
C
A nurse is caring for a client following an acute myocardial infarction. The client is concerned that providing self-care will be difficult due to extreme fatigue. Which of the following strategies should the nurse implement to promote the client's independence? a) request an occupational therapy consult to determine the need for assistive devices b) assign assistive personnel to perform self-care tasks for client c) instruct the client to focus on gradually resuming self-care tasks d) ask the client if a family member is available to assist with his care
C By gradually increasing performance of tasks, the client can feel a sense of accomplishment before taking on additional tasks.
A nurse is caring for a client in the immediate postoperative period. The nurse should recognize that which of the following positions moximizes the effectiveness of incentive spirometry? a) side-lying b) supine c) semi-fowler's d) trandelenburg
C HOB raised approximately 30 degrees allows for maximum expansion of the lungs
A nurse is performing a Romberg's test during the physical assessment of the client. Which of the following should the nurse use? a) touch the face with a cotton ball b) apply a vibrating tuning fork to the clients forehead c) have the client stand with arms at side and feet together d) perform direct percussion over the area of the kidneys
C Romberg's test assesses for alterations in balance therefore, the nurse should observe for swaying and a loss of balance
A nurse is caring for a client who has taken in 2,600 mL of fluids in 24 hr. Which of the following is an expected output for the client? a) 1,800 mL b) 2,100 mL c) 2,500 mL d) 3,200 mL
C The client's output should approximate the daily fluid intake
A client is receiving continuous tube feeding via NG tube. The client has 3 episodes of vomiting in 12 hr. Which of the following actions should the nurse take? a) flush the tube with 100 mL of water b) dilute the formula with sterile water c) aspirate for residual d) place the client in a supine position
C The nurse should aspirate for residual if vomiting occurs, as this can indicate the client is not absorbing the nutrients
A hospice nurse is providing end-of-life care to a client who has terminal lung cancer. The client states, "I am so tired and afraid of not being able to catch my breath." Which of the following is an appropriate response by the nurse? a) "We should restrict your visitors so that you can get more rest" b) "shortness of breath is temporary and should subside" c) "I will be able to give you more a medication to help your breathing" d) "fatigue is a common experience among hospice clients"
C the nurse can administer bronchodilators, inhaled steroids, or opiates to promote comfort and ease breathing, air hunger, and apprehension for clients who are terminally ill and are experiencing shortness of breath
A nurse is caring for a client with cancer who lives at home with her spouse. The spouse tells the nurse that the client is in pain "all of the time." Which of the following actions is most appropriate for the nurse to take? a) assess the client's vital signs b) assess the spouses understanding of the clients pain c) ask the spouse how he has been managing the client's pain d) ask the client to rate her pain
D
A nurse is completing an admission assessment of an older adult client. Which of the following findings is a potential indication of abuse? a) loss of skin turgor on the back of the hands b) varicosities on lower extremities c) thickened discolored nail with ridges d) presence of bruises on the arm in various stages of healing
D
A nurse is educating a family member of a client who is immobile about how to prevent back injury associated with moving the client up in bed. Which of the following statements by the family member should indicate to the nurse that he understands the teaching? a) "I will relax my abdominal muscles when preparing to move her" b) "I will keep my knees straight and my feet together" c) I will move back from the bed and bend at the waist" d) I will leverage my weight against my wife and shift as I move her"
D
A nurse is providing teaching about a clear liquid diet. Which of the following should the nurse instruct the client to avoid? a) lemon-lime sports drinks b) ginger ale c) black coffee d) orange sherbet
D
A nurse is reviewing practice guidelines with a group of newly licensed nurses. Which of the following interventions falls within the RN scope of practice? a) insert an implanted port b) close a laceration with sutures c) place an endotracheal tube d) initiate en enteral feeding through a PEG tube
D
A nurse is speaking with the parent of an infant who has a cardiac defect. After the parent expresses concern, which of the following is an appropriate response? a) "Do any of your other children have congenital defects?" b) "Is anything concerning you that I can explain?" c) "She is going to grow up to be a healthy child" d) "Tell me about your baby while I bathe her"
D
A nurse is conducting a respiratory assessment for four clients. Which of the following should the nurse recognize as an abnormal respiratory assessment finding? a) a male client who has diaphragmatic breathing b) a female client who has a thoracic muscle movement while breathing c) an infant who has irregular breathing pattern d) an adolescent who has visible accessory muscle movement when breathing
D An adolescent who has visible accessory muscle movement when breathing is demonstrating labored breathing
A charge nurse is observing a newly hired nurse prepare a sterile field. Which of the following indicates to the charge nurse that the sterile field is contaminated? a) Outer edges of the sterile field is touching a bottle b) first fold is opened away from the body c) sterile objects are held above the waist d) sterile field is opened on a wet surface
D Opening a sterile field on a wet surface contaminates it because capillary action can wick bacteria through the dressing
A nurse in a long-term care facility is planning to perform hygiene care for a new resident. Which of the following assessment questions is the nurse's priority before beginning this procedure? a) "When do you usually bathe, in the morning or the evening?" b) "Do you prefer a bath or shower?" c) "At what temperature do you prefer your bath water?" d) Are you able to help with your hygiene care?"
D The greatest risk to the client's safety is an injury from an overestimation of the client's ability to help with hygiene care.
A nurse is assisting a client with range of motion exercise of the neck. Which of the following should the nurse suggest to promote neck rotation? a) move her neck backwards b) touch her chin to chest c) touch her ear to shoulder d) move her head from side to side
D *rotation is turning the head as far as possible to each side
A nurse is caring for a postoperative adult client who refuses to use an incentive spirometer following major abdominal surgery. Which of the following is the nurse's priority action? a) Request that a respiratory therapist discuss the technique for incentive spirometry b) Administer a pain medication to the client c) Chart the client's refusal to participate in health restorative activities d) Determine the reasons why the client is refusing the use the incentive spirometer
D *the first action of the nurse should be to use the nursing process and ASSESS the client first
A nurse is preparing to administer ampicillin 40mg/kg/day PO divided in equal doses every 6 hours to a toddler who weighs 10 kg. Available is ampicillin oral suspension 125/5 mL. How many mL should the nurse administer per dose?
mg x kg/day = X 40 mg x 10 kg = 400 mg 400 / 4 = 100 mg per dose is desired 125 mg / 5 mL = 100 mg / X mL X = 4
