HESI Fundamentals Practice Exam #1 Correct and Verified Answers Graded A

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HESI Fundamentals Practice Exam #1 Correct and Verified Answers Graded A

• The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which

client is likely to tolerate a higher level of pain?• Correct Answer: A 55y/o woman who has had moderate low back pain for 3 months • Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to relieve the pain. All other clients are having new experiences with pain.

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

administer this Rx?

• Correct Answer: 0800, 1200, 1600, 2000

• The nurse removes the dressing on a client's heel that is covering a pressure sore 1"

in diameter & 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?

• Correct Answer: One-inch pressure sore draining serous fluid

• The home health nurse visits an elderly female client who had a brain attack 3

months ago & is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's care?• Correct Answer: The nurse notes there are numerous scatter rugs throughout the house

• The nurse assesses an immobile, elderly male client & determines that his blood

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

• Correct Answer: Turn the client q2h

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• Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring.

• When caring for an immobile client, what nursing diagnosis has the highest priority?

• Correct Answer: Impaired gas exchange

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

• Correct Answer: Place the soiled linens in a pillow case & deposit them in the dirty linen hamper

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

bathing?

• Correct Answer: "I don't understand why I'm so weak & tired."

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

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

• Correct Answer: Serum albumin

• Rationale: Serum albumin has a long half-life.

• A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled

chemo & states that she's ready to go home to die. What intervention should the nurse initiate?• Correct Answer: Evaluate the client's mental status for competence to refuse treatment • Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the HCP is notified of the patient's wishes & a d/c RX is obtained.Advance directives & DNR are not necessary for competent client to refuse care.

• A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse,

"Will it hurt to have my tonsils & adenoids taken out?" Which response is best for the nurse to provide?• Correct Answer: "It may hurt, but we'll give you medicine to help you feel better."

• A low-sodium, low-protein diet is prescribed for a 45y/o client with renal

insufficiency & HTN, who gained 3lbs in the last month. The nurse determines that the client has been noncompliant with the diet, based on which report from the 24hr diet recall?

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• Choices:

• Snack of potato chips & diet soda
• Lunch of tuna, carrots, fruit & coffee
• Breakfast of eggs, bacon, toast & coffee
• Bedtime snack of crackers & milk

• Correct Answer: 2. Lunch of tuna, carrots, fruit & coffee (Note: Based on standard renal diet restrictions, tuna is high protein; however, the provided text implies a selection was required. If the answer key intended a specific choice from the provided text, please verify. Common NCLEX logic suggests 'tuna' is high protein and 'carrots/fruit' are generally okay, but 'bacon/eggs' (Choice 3) or 'chips' (Choice 1)

are often the distractors for sodium.) [Editor's Note: The source text implies

noncompliance, often "Lunch of tuna..." is selected in similar question banks due to high protein content in tuna if protein restricted, or Choice 1 for Sodium.]

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

being treated with an Unna's paste boot for leg ulcers due to chronic venous insufficiency?• Correct Answer: Check capillary refill of toes on lower extremity with Unna's paste boot • Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation. No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly removal is reasonable.

• Male client with nursing diagnosis of "spiritual distress". What intervention is best

for the nurse to implement when caring for this client?• Correct Answer: Use reflective listening techniques when the client expresses spiritual doubts.

• Rationale: Client should be consulted before involving chaplain.

• Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to

impending death." What intervention is best for the nurse to implement when caring for this client?• Correct Answer: Assist & support the client in establishing short-term goals.

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• Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to death.

• Nurse who puts meds in her uniform pocket to deliver to clients confides that after

arriving home, she found a hydrocodone tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?

• Correct Answer: Accused of diversion

• A signed consent form indicated a client should have an electromyogram, by a

myelogram was performed instead. Thought the myelogram revealed the cause of the client's back pain, the client filed a lawsuit against the nurse & HCP for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent which infraction?• Correct Answer: Assault & battery with deliberate intent to deviate from the consent form

• A 75y/o client who has a history of end stage renal failure & advancing lung cancer,

recently had a stroke. 2 days ago, the HCP d/c the client's dialysis treatments, stating that death is inevitable, but the client is disoriented & will not sign a DNR directive.What is the priority nursing intervention?

• Correct Answer: Determine who is legally empowered to make decisions

• The charge nurse assigns a nursing procedure to a new staff nurse who has not

previously performed the procedure. What action is most important for the new staff nurse to take?• Correct Answer: Refuse to perform the task that is beyond the nurse's experience • Rationale: According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency.

• Before administering a client's medication, the nurse assesses a change in the

client's condition & withholds the medication until consulting with the HCP. The dose is changed & the nurse administers the new Rx 1 hour later than originally scheduled.What action should the nurse implement in response to this situation?

• Correct Answer: Document the events that occurred in the nurses' notes.

• On the third postoperative day following thoracic surgery, a client reports feeling

constipated. Which intervention should the nurse implement to promote bowel elimination?