HESI Fundamentals Practice Exam

The nurse is instructing a client in the proper use of a metered-dose inhaler. Which instruction should the nurse provide the client to ensure the optimal benefits from the drug?

"Compress the inhaler while slowly breathing in through your mouth."

The nurse is teaching an obese client, newly diagnosed with arteriosclerosis, about reducing the risk of a heart attack or stroke. Which health promotion brochure is most important for the nurse to provide to this client?

"Decreasing Cholesterol Levels Through Diet"

While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

"How will this affect your present sexual activity?"

One week after being told that she has terminal cancer with a life expectancy of 3 weeks, a female client tells the nurse, "I think I will plan a big party for all my friends." How should the nurse respond?

"Planning a party and thinking about all your friends sounds like fun."

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

"This is a new pill I have never taken before."

An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

"When I watched you give yourself the injection, you did it correctly."

The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.)

---Place the client in a high Fowler position. ---Instruct the client to swallow after the tube has passed the pharynx.

Which step(s) should the nurse take when administering ear drops to an adult client? (Select all that apply.)

---Place the client in a side-lying position. ---Pull the auricle upward and outward.

The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.)

0.8 mL

The nurse is counting a client's respiratory rate. During a 30-second interval, the nurse counts six respirations and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. Which respiratory rate should the nurse document?

16

A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?

ANA's Scope and Standards of Nursing Practice

The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure?

Administer water between the doses of the two liquid medications.

A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should the nurse respond?

Ask him to rate his pain on a scale of 1 to 10.

The nurse is teaching a client how to perform progressive muscle relaxation techniques to relieve insomnia. A week later the client reports that he is still unable to sleep, despite following the same routine every night. Which action should the nurse take first?

Ask the client to describe the routine he is currently following.

During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

Ask the client to talk about specific concerns.

A client in a long-term care facility reports to the nurse that he has not had a bowel movement in 2 days. Which intervention should the nurse implement first?

Assess the client's medical record to determine the client's normal bowel pattern.

Ten minutes after signing an operative permit for a fractured hip, an older client states, "The aliens will be coming to get me soon!" and falls asleep. Which action should the nurse implement next?

Assess the client's neurologic status.

An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?

Assist the client to walk to the bathroom and do not leave the client alone.

The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client?

Broiled fish, green beans, and an apple

After the nurse tells an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly verbalizing a dislike for all health care providers and nurses. How should the nurse respond?

Calmly reassure the client that the discomfort will be temporary.

A 65-year-old client who attends an adult daycare program and is wheelchair-mobile has redness in the sacral area. Which instruction is most important for the nurse to provide?

Change positions in the chair at least every hour.

The nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next?

Check for kinks in the tubing and raise the IV pole.

In assisting an older adult client prepare to take a tub bath, which nursing action is most important?

Check the bath water temperature.

A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?

Compare the current reading with the client's previously documented blood pressure readings.

The nurse transcribes the postoperative prescriptions for a client who returns to the unit following surgery and notes that an antihypertensive medication that was prescribed preoperatively is not listed. Which action should the nurse take?

Contact the health care provider to renew the prescription for the medication.

A female client with frequent urinary tract infections (UTIs) asks the nurse to explain her friend's advice about drinking a glass of juice daily to prevent future UTIs. Which response is best for the nurse to provide?

Cranberry juice stops pathogens' adherence to the bladder.

In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

Daily black, sticky stool

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

Decrease intake of fluids after the evening meal.

When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first sound was heard. Which is the best action for the nurse to take?

Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.

During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?

Description of the family's home environment

The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?

Determine if pain is causing the client's tachypnea.

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

Determine the client's usual bedtime routine and include these rituals in the plan of care as safety allows.

When performing sterile wound care in the acute care setting, the nurse obtains a bottle of normal saline from the bedside table that is labeled "opened" and dated 48 hours prior to the current date. Which is the best action for the nurse to take?

Discard the saline solution and obtain a new unopened bottle.

The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?

Discuss the client another time.

The nurse who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?

Do not give the medication and document the reason.

The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. Which action should the nurse take next?

Document that the client responds to painful stimulus.

Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?

Dorsiflex and plantarflex the feet 10 times each hour.

Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?

Encourage frequent ambulation in the hallway.

After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond?

Encourage the client to call the clinic nurse or health care provider if any questions arise.

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

Encourage the client to see the clinic's grief counselor.

A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment?

Explain the relationship to the charge nurse and ask for reassignment.

The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client to a chair, the client starts to fall. Which is the priority action for the nurse to take?

Gently lower the client to the floor.

Which nursing diagnosis has the highest priority when planning care for a client with an indwelling urinary catheter?

High risk for infection

When the health care provider diagnoses metastatic cancer and recommends a gastrostomy for an older female client in stable condition, the son tells the nurse that his mother must not be told the reason for the surgery because she "can't handle" the cancer diagnosis. Which legal principle is the court most likely to uphold regarding this client's right to informed consent?

If informed consent is withheld from a client, health care providers could be found guilty of negligence.

In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.

Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?

Leave the catheter in place and reattempt with another catheter.

The nurse is aware that malnutrition is a common problem among clients served by a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

Low serum albumin level

Based on the nursing diagnosis of risk for infection, which intervention is best for the nurse to implement when providing care for an older incontinent client?

Maintain standard precautions.

By rolling contaminated gloves inside-out, the nurse is affecting which step in the chain of infection?

Mode of transmission

The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home?

Observe the client change the dressing unassisted.

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

Perform range-of-motion exercises to prevent contractures.

A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first?

Pulse characteristics

When turning an immobile bedridden client without assistance, which action by the nurse best ensures client safety?

Put bed rails up on the side of bed opposite from the nurse.

When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?

Record the amount on the client's fluid output record.

During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?

Remind the client to walk carefully down the stairs until reaching a lower floor.

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

Retract the foreskin gently to cleanse the penis.

A client becomes angry while waiting for a supervised break to smoke a cigarette outside and states, "I want to go outside now and smoke. It takes forever to get anything done here!" Which intervention is best for the nurse to implement?

Review the schedule of outdoor breaks with the client.

The nurse selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the nurse use to identify placement of the IV access?

Right cephalic vein

Which client is most likely to be at risk for spiritual distress?

Roman Catholic woman considering an abortion

After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement?

Select another sterile needle.

Which nonverbal action should the nurse implement to demonstrate active listening?

Sit facing the client.

Which serum laboratory value should the nurse monitor carefully for a client who has a nasogastric (NG) tube to suction for the past week?

Sodium

Which action should the nurse implement when providing wound care instructions to a client who does not speak English?

Speak directly to the client, with an interpreter translating.

The nurse teaches the use of a gait belt to a male caregiver whose wife has right-sided weakness and needs assistance with ambulation. The caregiver performs a return demonstration of the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?

Standing on his wife's weak side, the caregiver provides security by holding the gait belt from the back.

The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement?

Stay with the client while the client is standing.

The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?

Taking anticoagulants for the past year

The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?

Talk to the client and attempt to find out why the client is crying.

A seriously ill female client tells the nurse, "I am so tired and in so much pain! Please help me to die." Which is the best response for the nurse to provide?

Talk with the client about her feelings related to her own death.

A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?

Teach the importance of personal hygiene during menstruation with the client.

The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention?

The UAP auscultates the popliteal pulse with the cuff on the lower leg.

The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?

The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.

A nurse stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later the client has to have the leg amputated and sues the nurse for malpractice. Which is the most likely outcome of this lawsuit?

There will be no judgment against the nurse, whose actions were protected under the Good Samaritan Act.

A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse do first?

Turn off the intermittent suction device.

The nurse identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?

Use of careful handwashing technique

When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?

With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.