HESI Fundamentals Exam Correct and Verified Answers Graded A

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HESI Fundamentals Exam Correct and Verified Answers Graded A

• The nurse working in the emergency department is assessing four clients' ability to

tolerate pain. Which client is likely to tolerate a higher level of pain?

• A 23-year-old woman who sprained her knee while biking
• A 55-year-old woman who has had moderate low back pain for three months
• A 10-year-old who was burned by a camp fire earlier today
• A 70-year-old who has a postoperative infection from a surgery one week ago

Correct Answer: B. a 55-year-old woman who has had moderate low back pain for three months

• A medication is prescribed to be given QID. What schedule should the nurse use to

administer this prescription?

A. 800

B. 0800, 1200, 1600, 2000

• every other day at 0800

D. 0800, 1200, 1600, 2000, 0000, 0400

Correct Answer: B. 0800, 1200, 1600, 2000

• The nurse removes the dressing on a client's heel that is covering a pressure sore

one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record?

• stage 1 pressure sore draining sero-anguineous drainage
• one-inch pressure sore draining serous fluid
• pressure sore draining serous fluid

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• pressure sore on heel with a small amount of purulent drainage

Correct Answer: B. one-inch pressure sore draining serous fluid

• The home health nurse visits an elderly female client who had a brain attack three

months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's case?

• The client's pulse rate is 10 beats higher than it was at the last visit one week ago
• the client tells the nurse that she does not have much of an appetite today
• the husband, who is the caregiver, begins to weep when you ask how he is doing
• the nurse notes that there are numerous scatter rubs throughout the house

Correct Answer: D. the nurse notes that there are numerous scatter rubs throughout the house

• The nurse assess an immobile, elderly male client and determines that his blood

pressure is 138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the last hour. He has wet-sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is the most important for the nurse to implement?

• encourage additional additional fluid intake
• provide the client with an additional blanket
• turn the patient Q2
• administer a PRN anti hypertensive prescription

Correct Answer: C. turn the patient Q2

• When caring for an immobile client, what nursing diagnosis has the highest priority?
• altered tissue perfusion
• impaired gas exchange
• risk for fluid volume deficit
• risk for impaired skin integrity

Correct Answer: B. impaired gas exchange

• How should a nurse handle linens that are soiled with incontinent feces?

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• Place the soiled linens in a pillow case and deposit them in the dirty linen hamper
• put the soiled linens in an isolation bag, then place it in the dirty linen hamper
• Ask the housekeeping staff to pick up the soiled linen from the dirty utility room
• place an isolation hamper in the client's room and discard the linens in it

Correct Answer: D. place an isolation hamper in the client's room and discard the linens in it

• What client statement indicates to the nurse that the client requires assistance with

bathing?

• "I only bathe every other day"
• "I left my eyeglasses at home"
• "I don't understand why I'm so weak and tired"
• "I wasn't able to pack a bag before I left for the hospital"

Correct Answer: C. "I don't understand why I'm so weak and tired"

• A client with chronic renal disease is admitted to the hospital for evaluation prior to

a surgical procedure. Which laboratory test indicated the client's protein status for the longest length of time?

• Urine urea
• transferrin
• prealbumin
• serum albumin

Correct Answer: D. serum albumin

• A 35 year old female client with cancer refuses to allow the nurse to insert an IV for

a scheduled chemotherapy treatment, and states that she is ready to go home and die.What intervention should the nurse initiate?

• evaluate the client's mental status for competence to refuse treatment
• review the client's medical record for an advance directive
• determine if a DNR prescription has been obtained
• document that the client is being discharged against medical advice

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Correct Answer: A. evaluate the client's mental status for competence to refuse treatment

• A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the

nurse, " will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide?

• "It won't hurt because you're such a big boy"
• "It may hurt a little because of the incision made in your throat"
• "It won't hurt because we put you to sleep"
• "It may hurt but we'll give you medicine to help you feel better"

Correct Answer: D. "It may hurt but we'll give you medicine to help you feel better"

• A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal

insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been non compliant with the diet, based on which report from the 24-hour dietary recall? (select all that apply)

• bedtime snack of crackers and milk
• breakfast of eggs, bacon, toast, and coffee
• lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee
• dinner of vegetable lasagna, tossed salad, sherbet, and iced tea
• snack of potato chips, and diet soda

Correct Answer: A, B, C & E

• What intervention should the nurse include in the plan of care for a client who is

being treated with an Unna's paste boot for leg ulcers due to a chronic venous insufficiency?

• check capillary refill of toes on lower extremity with Unna's paste boot
• apply dressing to a wound area before applying the Unna's paste boot
• remove the Unna's paste boot Q8H to assess wound healing
• wrap the leg from the knee down towards to foot

Correct Answer: A. check capillary refill of toes on lower extremity with Unna's paste boot