Hesi Fundamentals Practice Exam

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.

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

upper arm circumference

when assisting an 82 y.o. client to ambulate, it is important for the nurse to realize that the cent of gravity for an elderly person is the?

upper torso

An obese male client discusses with the nurse his plans to begin a long-term weight loss region. in addition to dietary changes, he plans to begin an intensive aerobic exercise program 3-4 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?

"be sure to have a complete physical exam before beginning your planned exercise program"

the nurse is instructing a client with high cholesterol about diet and life stile 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"

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 this clients silence?

"it is OK if you don't want to take about your surgery, i will be available when you are ready"

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 preoperative assessment?

"what vitamin and mineral supplements do you take?"

the healer provider prescribes the diuretic metolazone (zaroxolyn) 7.5 mg po. zaroxolyn is available in 5mg tablets. how much should the nurse plan to administer

1 1/2 tablets

Seconal 150 mg PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled 0.1 grams per tablet. How many tablets should the nurse plan to administer?

1.5 tab

the healer provider prescribes furosemide (lasix) 15mg IV STAT. on hand is lasix 20mg/2mL. How many mL should the nurse administer

1.5mL

Heparin 20,000 units in 500 mL D5W at 50 mL/hour has been infusing for 5 hours. how much heparin has the client received?

11,000 units

The nurse mixes 50 mg of Nitride in 250 mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. using the drip factor of 60gtt/mL, how many drops per minute should the client receive

124 gtt/mL

an IV infusion terbutaline sulfate 5mg in 500 mL of D5W, infusing at a rate of 30 mug/min. is prescribed for a client in premature labor. how many mL/hr should the nurse set the infusion pump?

180

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?

21. (The accepted formula for figuring drops per minute is: amount to be infused in one hour × drop factor/time for infusion (min)= drops per minute. Using this formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C)

a client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours. at what rate should the nurse set the clients intravenous infusion pump?

63 mL/hour

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-relate capsules are not available, which does schedule should the nurse advise the client to follow?

8 am, 4pm and Midnight

The healthcare provider prescribes an IV infusion of 1,000 mL of LR with 30 units of piton to run in over 4 hours for a client who has just delivered a 10 pound infant by C-section. The tubing has been changed to a 20gtt/mL admin set. the nurse plans to set the flow rate at how many gtt/min?

83 gtt/min

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 woman nursing her 3-day-old infant.

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 client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h 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.

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 Acceptance that she is not being punished by God indicates a desired outcome

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?

Acknowledge that she is supporting the arm correctly.

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.

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.

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?

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

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

Genetic and familial health disorders A genogram that is used during the health assessment process identifies genetic and familial health disorders (A). It may not identify the client's chronic health problems

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 client's primary health problem?

Closed-ended questions Lay descriptors of health problems can be vague and nonspecific. To efficiently obtain specific information, the nurse should use closed-ended questions (C) that focus on common signs and symptoms about a client's health problem

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

Continue asking the mother questions about the child.

An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is

Fowler's.

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?

Frontal lobe

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 client's knee joint.

A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium 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 The results are all within normal range.(C) No changes are needed.

during the initial 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 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 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.

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.

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?

Immediately after the assessments are completed.

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.

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?

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 An implanted infusion port needs to be accessed using a Huber-point needle (B) (non-coring) to be prevent damage to the self-sealing septum of the port.

An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response?

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

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 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 When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings

Exam 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.

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?

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

A client's infusion of normal saline infiltrated earlier today, and approximately 500 ml 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. Pain and diminished pulse volume are signs of compartment syndrome, which can progress to complete loss of the peripheral pulse in the extremity. Compartment syndrome occurs when external pressure (usually from a cast), or internal pressure (usually from subcutaneous infused fluid), exceeds capillary perfusion pressure resulting in decreased blood flow to the extremity.

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

Mix each medication individually Medications should be mixed separately (A) to prevent clumping.

The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with 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.

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?

Notify the healthcare provider of the family's 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.

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 this client's teaching plan?

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

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?

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

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?

Re-oxygenate the client before attempting to suction again.

The nurse observes an unlicensed assistive personnel (UAP) taking a client's 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 client's blood pressure using a larger cuff.

The 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.

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?

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

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 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?

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

An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client?

Tell the surgeon that the son will decide after explanation of the proposed surgery is provided. Traditional Muslim women live in a patriarchal family where decisions are made by men. Most likely, the son will make the decision for his mother, so

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?

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

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 elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment?

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

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 Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest

a hospitalized male client is receiving NGT 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?

after clearing the tube with 30mL of air, check the pH of the fluid withdrawn from the tube

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

assess for bladder distention

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

chocolate pudding

a client with chronic kidney diseases CKD selects a scrambled egg for his breakfast. what action should the nurse take?

commend the client for selecting a hight biologic value protein

a postoperative client will need to perform daily dressing changes after discharge, which outcome statement best demonstrates the clients readiness to manage his wound care after discharge? the client.....

demonstrates 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 teaching a client proper use of an inhaler. when should the client administer the inhaler-delivered medication to demonstrated correct use of the inhaler?

during the inhalation

a client with acute hemorrhagic anemia is to receive four units of packed RBC's as rapidly as possible, which intervention is most important for the nurse to implement?

ensure the accuracy of the blood type match

which assessment date provides the most accurate determination of proper placement of a NGT?

examining a chest x-ray obtained after the tubing was inserted

the nurse is caring for a client who is received 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. when initially assessing the client. the nurse notes that the 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 54 mL/hour

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

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

when evaluation 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

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

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

often follows relocation to new surroundings

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

reposition the client on her side