HESI Fundalmentals Exam

Which information will the nurse consider when planning care for a client with human immunodeficiency virus (HIV) who has been diagnosed with class 3 tuberculosis? Select all that apply. One, some, or all responses may be correct.

-Class 3 tuberculosis is a clinically active disease, which is contagious. -Tuberculosis is the leading cause of mortality in clients infected with HIV. -Persons with active tuberculosis are usually treated on an outpatient basis.

The nurse would intervene to prevent unlicensed assistive personnel (UAP) from providing which food to a woman with hyperemesis gravidarum?

Scrambled eggs

Which activity would help prepare a client to care for her preterm infant who is in the neonatal intensive care unit?

She will be encouraged to participate in the infant's care as much as possible.

The nurse is providing discharge teaching for the parents of a child with acute laryngotracheobronchitis. Which would the nurse instruct the parents to do to control symptoms at home?

Start a cool-mist humidifier close to the child.

A client with quadriplegia attends tilt table therapy daily and asks why the angle of the table gradually increases each day. Which response would the nurse use?

The tilt table provides therapeutic weight bearing to limit loss of calcium from the bones.

Which information would the nurse provide to the client who is to have a pelvic examination on her first visit to the prenatal clinic?

The uterus will be assessed for growth.

Which intervention would the nurse implement for a client in alcohol detoxification who reports numbness and tingling in the feet and legs?

Keeping the bed linens off the client's legs with a mechanical aid

Which type of respiratory pattern would the nurse expect in a client with metabolic acidosis?

Kussmaul breathing

A client with burns over 35% of the body reports chilling. Which action will the nurse take to promote client comfort?

Limit room drafts.

The parents of a toddler with newly diagnosed cystic fibrosis ask the nurse what causes the problems related to this disorder. Which would the nurse consider about the primary pathologic process before responding?

Mechanical obstruction of mucus-secreting glands

Which finding would the nurse expect when assessing a client who has right ventricular failure?

Neck vein distention

Which would the nurse do first for a client with pink raised areas that are swollen and itchy after using a new soap?

Perform a full history and physical examination.

Which statement made by the nurse indicates the need for further teaching when assessing clients with dark skin?

"I will use a fluorescent light source to assess the skin color."

Which interventions would the nurse include in the plan of care for a preschooler diagnosed with celiac disease? Select all that apply. One, some, or all responses may be correct.

-Avoiding processed foods -Adding oat products to the diet -Administering a fat-soluble vitamin supplement -Obtaining a dietary prescription

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), which would the nurse do?

Administer oxygen at a low concentration to maintain respiratory drive.

Which action would the nurse take when caring for a client on the first postoperative day after a femoral-popliteal bypass graft?

Assist the client with ambulation.

When a client with a history of chronic myelogenous leukemia and splenomegaly is admitted to the hospital, which finding will the nurse expect during the assessment?

Left upper quadrant tenderness

A toddler with a repaired myelomeningocele has urinary incontinence and some flaccidity of the lower extremities. Which would the nurse teach the parents?

The child will probably require a program of intermittent straight catheterization.

A 7-year-old child must remain quietly in bed while undergoing peritoneal dialysis. Which activity is most appropriate for the nurse to plan for this child?

Working multiple-piece puzzles

The nurse is caring for a client who is terminally ill with cancer. The health care team meets and agrees to provide the client with information to help the client make decisions regarding treatment. Which ethical principles are applied in this situation? Select all that apply. One, some, or all responses may be correct.

-justice -fidelity -veracity -autonomy

Which findings in a client seen at the outpatient clinic support a diagnosis of an arterial ulcer? Select all that apply. One, some, or all responses may be correct.

-lack of hair -thickened toenails -diminished pedal pulse

A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy would the nurse assess this client? Select all that apply. One, some, or all responses may be correct.

-mental confusion -increased cholesterol -musty sweet breath

Which symptom would the nurse expect the client who has primary open-angle glaucoma to report?

Decreased peripheral vision

A client complains to the nurse manager about a coworker. The nurse manager listens to both the client's and the coworker's sides of the story. Which critical thinking quality is shown in this situation?

Fairness

After a tonsillectomy, which early clinical finding would alert the nurse to suspect a possible hemorrhage?

Frequent swallowing

Which parent education would the nurse provide for a 1-year-old infant who drinks from four to six full bottles of milk per day and has a hemoglobin level of 9 g/dL (90 mmol/L)?

Give the infant finger foods such as baby cereal and soft meats.

Which factor increases the risk of respiratory complications in clients with myasthenia gravis?

Ineffective coughin

Which conclusion would the day nurse make about a client with anorexia nervosa who states that the day nurses give better care and are nicer than the night nurses?

Is trying to divide the staff, and the behavior should be reported to the other staff members

Why is it important for the nurse to know the infant's gestational age and how it compares with the birth weight?

Potential problems may be identified.

Which signs would alert the nurse that the client needs to take a break from practicing crutch walking?

Profuse diaphoresis and rapid respirations

A client with a parathyroid disorder reports nausea, vomiting, weight loss, and epigastric pain. Which electrolyte disturbance would be responsible for the client's clinical manifestations?

Hypercalcemia

Which statement of the client would the nurse consider to be a self-esteem need based on Maslow's hierarchy of needs?

"I deserve ill treatment from my husband because I'm incapable of doing even simple things perfectly."

Which response would the nurse provide to a perimenopausal woman who asks about complementary treatment options for hot flashes?

"Try eating more soy-rich foods such as yams, cherries, alfalfa sprouts, black beans, and soybeans."

The nurse is providing education about care of the residual limb to a client who had a below-the-elbow amputation. Which information will the nurse include in the teaching session?

"Wash and dry the residual limb at least once a day."

A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required?

"We'll have to have the baby fitted with prosthetic devices before the baby is able to walk."

Which statement indicates that the parents of a child who will continue chemotherapy treatment at home understand the discharge instructions?

"We'll let her eat at her own pace."

Which suggestion for coping with morning sickness would the nurse give to a pregnant client?

"Eat protein before bedtime."

The nurse is assessing a pediatric client diagnosed with chronic renal failure exhibiting alterations in growth patterns. When educating the client's parents about the child's growth, which statement is accurate?

"Resistance to growth hormone associated with your child's diagnosis is causing poor growth."

An older adult is found to have a thin white ring around the margin of the iris. Which condition would this suggest?

Arcus senilis

Which action would the nurse perform first when prioritizing care for a hypertensive client?

Assess for a severe headache.

Which injury is consistent with a client who has blood draining from the left ear and rhinorrhea after a motor vehicle crash?

Basilar fracture

The nurse is caring for an older adult client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment information best reflects the fluid balance of this client?

Blood lab results

After the surgical creation of an ileostomy, a client is transferred to a rehabilitation unit. The client asks for help in selecting breakfast foods. Which items would the nurse recommend?

Cream of wheat cereal and bananas

Which is the best time for the nurse to teach simple breathing and relaxation techniques to a client in labor who has not attended any childbirth classes?

During the latent phase of the first stage of labor

The parent of an infant with Down syndrome asks the cause. Before responding, the nurse recalls that the genetic factor of Down syndrome results from which?

Extra chromosomal material

After a gastrojejunostomy (Billroth II) for cancer of the stomach, a client returns to a regular diet. After eating lunch, the client becomes diaphoretic and experiences palpitations. Which would the nurse conclude is the probable cause of these clinical manifestations?

Extracellular fluid shift into the bowel

Damage to which nerve explains why a client recovering from a head injury is unable to move the tongue?

Hypoglossal

Which clinical manifestation is observed in a client with adrenal insufficiency?

Hyponatremia

Which client behavior indicates to the nurse that further teaching regarding breast-feeding her newborn is needed?

If she leans forward to place her breast in the infant's mouth

The nurse teaches a client with acquired immunodeficiency syndrome (AIDS) to avoid consuming undercooked meat as a means of preventing which infection?

Toxoplasmosis encephalitis

Which immunizations would the nurse expect a 5½-month-old infant to have already received if the immunization status is considered up to date?

Two doses of diphtheria, tetanus, and pertussis vaccine

The nurse is assessing a client with a tentative diagnosis of hydatidiform mole. Which clinical finding would the nurse anticipate?

Unusual uterine enlargement

Which responsibilities would the nurse leader incorporate when using the National Council of State Boards of Nursing (NCSBN) Delegation Model to support safe, quality and efficient client care in reviewing unit policies related to delegation? Select all that apply. One, some, or all responses may be correct.

-Promote a positive culture and work environment. -Determine nursing responsibilities that can be delegated. -Identify to whom nursing responsibilities can be delegated. -Delineate under what circumstances nursing responsibilities can be delegated.

Which action would the nurse take to prevent postoperative respiratory complications after abdominal surgery?

Assist with incentive spirometry.

Which task in the care of a client with neutropenia can be delegated to unlicensed assistive personnel (UAP)?

Assisting with personal hygiene

Which diet would the nurse anticipate for an infant with phenylketonuria?

Low-phenylalanine

At 32 weeks' gestation a client undergoes an ultrasound examination, which reveals a low-lying placenta. Which assessment finding would the nurse anticipate as the client's pregnancy approaches term?

Painless vaginal bleeding

A preterm neonate is receiving oxygen by way of an overhead hood. Which nursing interventions would the nurse implement to protect the infant under the oxygen hood?

Put a hat on the infant's head to prevent hypothermia.

The registered nurse (RN) oversees five unlicensed nursing personnel (UNP), and each UNP cares for five clients, so the RN in effect has responsibility for five UNPs and 25 clients. Which term best describes the relationship between the number of subordinates and clients and the RN?

Span of control

The nurse is providing care for a client who is hospitalized for dehydration and expects which assessment findings? Select all that apply. One, some, or all responses may be correct.

-Postural hypotension -The skin on the client's forehead remains tented after being pinched

A client with gastroesophageal reflux disease (GERD) needs to make dietary and lifestyle changes. Which instructions would the nurse include in the client's discharge teaching? Select all that apply. One, some, or all responses may be correct.

-Encourage the client to quit smoking. -Avoid lying down for 2 to 3 hours after eating.

Which processes are functions of antidiuretic hormone? Select all that apply. One, some, or all responses may be correct.

-Increasing arteriole constriction -Increasing tubular permeability to water

Which interventions are included in the immediate care plan of a postpartum client with a fourth-degree laceration? Select all that apply. One, some, or all responses may be correct.

-Pain management with oral analgesics -Assessment of the site every 15 minutes -Application of an ice pack for 20-minute intervals

Which statements about preschoolers are accurate? Select all that apply. One, some, or all responses may be correct.

-They can ride a tricycle. -Their thinking is often described as magical thinking. -They use language without comprehending the meaning of words.

A client receiving a hemodialysis treatment asks the nurse which substances are being removed. Which substance can the nurse report is being removed during hemodialysis?

Sodium

The nurse is going through a pilot research study that aims to identify the effectiveness of using an experimental therapeutic communication technique when dealing with aggressive clients. This describes which type of study?

exploratory research

The nurse, caring for a client with full-thickness burns of the anterior trunk and thigh, is monitoring fluid balance during the first 2 to 3 days after the burn. Which area is most important for the nurse to assess for fluid balance in this client?

Urinary output every hour

The nurse provides dietary teaching for a client with an acute exacerbation of ulcerative colitis, and afterward the client makes a list of foods that can be included in the diet. Which food choices indicate that the teaching by the nurse is effective? Select all that apply. One, some, or all responses may be correct.

-Scrambled eggs -jelly sandwich -lean roast beef

Which information is most important to include when the nurse is teaching a client who has had an ST segment elevation myocardial infarction (STEMI) about the purpose of salt restriction?

Salt intake increases the work of the heart.

A client who had an open reduction and internal fixation of a femoral neck fracture has a prescription for ambulation with slight weight bearing on the affected extremity. The nurse identifies that the client has kyphosis and strong upper-arm strength. Which assistive device would the nurse expect the primary health care provider to prescribe?

Walker

The nurse is taking care of a client with cirrhosis of the liver and ascites. Which lunch is an appropriate choice for a client with this disorder?

Penne pasta, spinach, banana, and decaffeinated iced tea

Which statements are true regarding primary nursing care developed by Manthey as a method for organizing client care? Select all that apply. One, some, or all responses may be correct.

-The associate nurse provides input for the client's plan of care -If the client develops complications, the associate nurse should notify the primary nurse. -The registered nurse (RN) functions autonomously as the primary nurse throughout the client's hospital stay.

Which points about restorative care are accurate? Select all that apply. One, some, or all responses may be correct.

-The restorative health care team consists of health professionals, the client, and the caregiver(s). -Success depends on effective and early collaboration with clients and their families. -Clients and families follow treatment plans better when they are involved in restorative care. -Restorative care is provided through home health care, rehabilitation, or extended care facilities.

Which physical assessment findings would the nurse document on a client who is experiencing Cushing triad? Select all that apply. One, some, or all responses may be correct.

-bradycardia -irregular respirations -systolic hypertension -widening pulse pressure

The nurse is explaining to a parent about Freud's theory of child development. Which stages would the nurse include in the discussions? Select all that apply. One, some, or all responses may be correct.

-phallic stage -latency stage

As part of an infertility workup involving both partners, a male client is to have a semen analysis. Which instruction would the nurse give him?

Deliver the specimen to the laboratory within 2 hours of obtaining it.

When a client in the emergency department is diagnosed with pneumonia and has a high CURB-65 score, which prescribed action by the health care provider would the nurse question?

Discharge home with follow-up by client's health care provider in the morning.

A client arrives in the emergency department unconscious and exhibiting decerebrate posturing. Which positioning behaviors would the nurse expect to observe?

Hyperextension of both the upper and lower extremities

A client placed on bed rest has acute arthritis and reports bilaterally painful hips and swollen knee joints. Which position prevents flexion deformities during the acute phase of the client's care?

Prone

The nurse documents the data gathered during the assessment in a client's medical record. Which would the nurse do to ensure that the data is meaningful to other health care providers?

Record objective information using accurate terminology.

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?

Respiratory alkalosis

Which outcome indicates range-of-motion exercises have been effective for a child with juvenile idiopathic arthritis (JIA)?

The knees are more mobile.