Foundations HESI Practice Exam

The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? "If I exercise at least two times weekly for one hour, I will lower my cholesterol." "I need to avoid eating proteins, including red meat." "I will limit my intake of beef to 4 ounces per week." "My blood level of low density lipoproteins needs to increase."

"I will limit my intake of beef to 4 ounces per week." Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins need to decrease rather than increase.

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 is your daily calorie consumption?" "What vitamin and mineral supplements do you take?" "Do you feel that you are overweight?" "Will a clear liquid diet be okay after surgery?"

"What vitamin and mineral supplements do you take?" In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact the medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery.

The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A college-age track runner with a sprained ankle. A lactating woman nursing her 3-day-old infant. A school-aged child with Type 2 diabetes. An elderly man being treated for a peptic ulcer.

A lactating woman nursing her 3-day-old infant. A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, typoe 2 diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased metabolic protein demands of lactation.

A hospitalized male client is receiving nasogastric tube feedings 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? Record the coughing incident. No further action is required at this time. Stop the feeding, explain to the family why it is being stopped, and notify the healthcare provider. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small-bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any other action. The auscultating method has been found to be unreliable for small-bore feeding tubes.

On admission, a client presents 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? Assault. Battery. Malpractice. False imprisonment.

Battery. Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching). Performing any procedure against the client's wishes can potentially poise a legal issue, such as battery (B), even if the procedure is of questionable benefit to the client. (A, C, and D) are not examples against the client's request.

The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? Bewilderment is to be expected, and progresses with age. Disorientation often follows relocation to new surroundings. Uncertainty is a result of irreversible brain pathology. Being perplexed can be prevented with adequate sleep.

Disorientation often follows relocation to new surroundings. Relocation often results in confusion among elderly clients--moving is stressful for anyone. Advancing confusion with age is a stereotypical judgment. Stress in the elderly often manifests itself as confusion. Adequate sleep is not prevention for the confusion.

Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? Aspirating gastric contents to assure a pH value of 4 or less. Hearing air pass in the stomach after injecting air into the tubing. Examining a chest x-ray obtained after the tubing was inserted. Checking the remaining length of tubing to ensure that the correct length was inserted.

Examining a chest x-ray obtained after the tubing was inserted. Assessing the pH of gastric contents and listening for air in the stomach are both methods used to determine the proper placement of the nasogastric tube. However, the best indicator that the tube is properly placed is confirming with a chest x-ray.

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? Clamp the tube for 20 minutes. Flush the tube with water. Administer the medications as prescribed. Crush the tablets and dissolve in sterile water.

Flush the tube with water The NGT should be flushed before, after and in between each medication administered (B). Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C and D) may be implemented only after the tubing has been flushed.

A client who is in hospice care reports 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 the administration of analgesics. Administer analgesic medication as needed when the pain is severe. Provide medication to keep the client sedated and unaware of stimuli. Offer a medication-free period so that the client can do daily activities.

Give an around-the-clock schedule for the administration of analgesics. The most effective management of pain is achieved using an around-the-clock schedule that provides analgesic medications on a regular basis and in a timely manner. Analgesics are less effective if pain persists until it is severe, so an analgesic medication should be administered before the client's pain peaks. Providing comfort is a priority for the client who is dying, but sedation that impairs the client's ability to interact and experience the time before life ends should be minimized. Offering a medication-free period allows the serum drug level to fall, which is not an effective method to manage chronic pain.

At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? At the beginning, middle, and end of the shift. After client priorities are identified for the development of the nursing care plan. At the end of the shift so full attention can be given to the client's needs. Immediately after the assessments are completed.

Immediately after the assessments are completed. Documentation of client findings should occur immediately after any component of the nursing process, so assessments should be entered in the client's medical record as readily as findings are obtained.

The unlicensed assistive personnel (UAP) 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? Place the chair at a right angle to the bed on the client's left side before moving. Assist the client to a standing position, then place the right hand on the armrest. Have the client place the left foot next to the chair and pivot to the left before sitting. Move the chair parallel to the right side of the bed, and stand the client on the right foot.

Move the chair parallel to the right side of the bed, and stand the client on the right foot. When positioning a client for transfer from bed to chair when the client has left-sided weakness, use the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the client should stand on the right foot during the transfer.

A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? Sexual activity patterns. Nutritional history. Leisure activities. Financial stressors.

Nutritional history. Caffeine, sugars, and alcohol can lead to increased levels of anxiety, so a nutritional history (C) should be obtained first so that health teaching can be initiated if indicated. (A and C) can be used for stress management. Though (D) can be a source of anxiety, a nutritional history should be obtained first.

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. Instruct the client regarding the need for the covering. Reapply the covering after filling with fresh ice. Ask the client how long the ice was applied to the skin.

Observe the appearance of the skin under the ice pack. The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place.

An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? Generalized dry skin. Localized dry skin on lower extremities. Red flush over entire skin surface. Rashes in the axillary, groin, and skin fold regions.

Rashes in the axillary, groin, and skin fold regions. Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity.

The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? Encourage the client to cough to help loosen secretions. Advise the client to increase the intake of oral fluids. Rotate the suction catheter to obtain any remaining secretions. Re-oxygenate the client before attempting to suction again.

Re-oxygenate the client before attempting to suction again. Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen.

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? Remain calm with the client and record abnormal results in the chart. Notify the medication nurse immediately if the pulse or blood pressure is low. Report the results of the vital signs to the nurse. Reassure the client that the vital signs are normal.

Report the results of the vital signs to the nurse. Interpretation of vital signs is the responsibility of the nurse, so the unlicensed assistive personnel (UAP) should report vital sign measurements to the nurse. Any instructions requiring the UAP to interpret the vital signs causes the UAP to function beyond the scope of the UAP's authority.

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? Irrigate the nasogastric tube with sterile normal saline. Reposition the client on her side. Advance the nasogastric tube an additional five centimeters. Administer an intravenous antiemetic prescribed for PRN use.

Reposition the client on her side. The nurse has identified two things suggesting the the nasogastric tube is not functioning properly: client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first. This includes repositioning the client to her side. The tube may need to be irrigated or advanced but these actions should follow repositioning the client.

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 fluent English. Surgery is recommended for this client. What is the best plan to obtain consent for surgery for this client? Obtain an interpreter to explain the procedure to the client. Encourage the client to make her own decision regarding surgery. Ask the family members to provide a clarification of the surgeon's explanation to the client. Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow.

Tell the surgeon that the brother-in-law will decide after an explanation of the proposed surgery is provided to him and the widow. Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of her husband's brother. In those rural areas, women live in a patriarchal family where decisions are made by men. Most likely, the brother-in-law will make the decision for his inherited wife, so (D) provides the surgeon with culturally sensitive information. (A) all family members speak fluent English therefore there is no need for a translator; there is no language barrier. It is culturally insensitive to encourage the woman to go against her wishes and her cultural worldview, as in (B). Family members are more likely to misinterpret medical information (C).

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. The client fully understands the procedure. The client agrees with the procedure to be done. The client authorizes continued treatment.

The client voluntarily signed the form. The nurse signs the consent form to witness that the client voluntarily signs the consent (A), that the client's signature is authentic, and that the client is otherwise competent to give consent. It is the healthcare provider's responsibility to ensure the client fully understands the procedure (B). The nurse's signature does not indicate (C or D).

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

Upper arm circumference. Upper arm circumference (D) is an indirect measure of muscle mass. (A and B) do not distinguish between fat (adipose) and muscularity. (C) is a measure of body fat.