HESI Fundamentals Practice Exam 2023 to 2024

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Grand Canyon University *

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2023

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Nursing

Date

Nov 24, 2024

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HESI Fundamentals Practice Exam 2023 to 2024 The nurse encounters resistance when inserting the tubing into a client's rectum for a tap water enema. What action should the nurse implement? - Ask the client to relax and run a small amount of fluid into the rectum. The nurse is discussing dietary preferences with a client who adheres to a vegan diet. Which dietary supplement should the nurse encourage the client to include in the dietary plan? - Vitamin B12. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day.What is the best action for the nurse to implement when assisting the client from the bed to the chair? - Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? - Combination of plant proteins to provide essential amino acids. 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 may hurt but we'll give you medicine to help you feel better." When the nurse enters a client's room to do an initial assessment, the client shouts, "Get out of my room! I'm tired of being bothered!" How should the nurse respond? - "What is concerning you this morning?" Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? - Upon discharge, the client will list three ways to protect the feet from injury.

The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the nurse take next? - Cradle the client's heel. While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? - Instruct the client to take slow deep breaths and stop bearing down. What action should the nurse implement when adding sterile liquids to a sterile field? - Consider the sterile field contaminated if it becomes wet during the procedure. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum "tents" when gently pinched. Which action should the nurse implement? - Continue the planned nursing interventions to restore the client's fluid volume. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? - Take measures to promote as much comfort as possible. The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? - Draw up the irrigating solution into the syringe. The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous (IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the alarm on the infusion pump indicates an obstruction. What action should the nurse take first? - Reposition the client's arm. 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 chronic venous insufficiency? - Check capillary refill of toes on lower extremity with Unna's paste boot.

A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with a malodorous green drainage. Which dressing is best for the nurse to use first? - Wet to moist dressing. A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? - Herbs should be obtained from manufacturers with a history of quality control of their supplements. 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? - One-inch pressure sore draining serous fluid. 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? - Refuse to perform the task that is beyond the nurse's experience. A female client who has breast cancer with metastasis to the liver and spine is admitted with constant, severe pain despite around-the-clock use of oxycodone (Percodan) and amitriptyline (Elavil) for pain control at home. During the admission assessment, which information is most important for the nurse to obtain? - Sensory pattern, area, intensity, and nature of the pain. What action by the nurse demonstrates culturally sensitive care? - Asks permission before touching a client. A client in hospice care develops audible gurgling sounds on inspiration. Which nursing action has the highest priority? - Inform the family that death is imminent. A client who has moderate, persistent, chronic neuropathic pain due to diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step 2 of the World Health Organization

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(WHO) pain relief ladder is prescribed, which drug protocol should be implemented? - Continue gabapentin. When preparing to administer an intravenous medication through a central venous catheter, the nurse aspirates a blood return in one of the lumens of the triple lumen catheter. Which action should the nurse implement? - Flush the lumen with the saline solution and administer the medication through the lumen. How should the nurse handle linens that are soiled with incontinent feces? - Place the soiled linens in a pillow case and deposit them in the dirty linen hamper.. An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first? - Drape the sheets over the footboard of the bed. A healthcare provider is performing a sterile procedure at a client's bedside. Near the end of the procedure, the nurse observes the healthcare provider contaminate a sterile glove and the sterile field. What is the best action for the nurse to implement? - Identify the break in surgical asepsis and provide another set of sterile supplies. The nurse notes that a client consistently coughs while eating and drinking. Which nursing diagnosis is most important for the nurse to include in this client's plan of care? - Risk for aspiration. In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation while the client is in a supine position. What action should the nurse implement? - Document the presence and volume of the pulse palpated. A male nurse is assigned to care for a female Muslim client. When the nurse offers to bathe the client, the client requests that a female nurse perform this task. How should the male nurse respond? - "I will ask one of the female nurses to bathe you."

Which client care activity requires the nurse to wear barrier gloves as required by the protocol for Standard Precautions? - Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. A male client has a nursing diagnosis of "spiritual distress." What intervention is best for the nurse to implement when caring for this client? - Use reflective listening techniques when the client expresses spiritual doubts. 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. The nurse is assisting an 82-year-old client to ambulate. Which is the center of gravity for an elderly person? - Upper torso. 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. 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. The nurse observes an unlicensed assistive personnel (UAP) checking 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. Which action is most important for the nurse to implement? - Reassess the client's blood pressure using a larger cuff. A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) - 2

A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge? - Demonstrating the wound care procedure correctly. A client receives a prescription for azithromycin (Zithromax) 500 mg PO x 3 days. Azithromycin is available as 250 mg scored tablets. How many tablets should the nurse administer per dose? (Enter the numerical value only.) - 2 A client who has a sinus infection is receiving a prescription for amoxicillin/clavulanate potassium (Augmentin) 500 mg PO q8 hours. The available form is 250 mg amoxicillin/125mg clavulanate tablets. How many tablets should the nurse administer for each dose? (Enter numeric value only.) - 2 An older 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. 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. An older 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. 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. A client with acute hemorrhagic anemia is to receive four units of packed red blood cells (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? - Ensure the accuracy of the blood type match.

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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? - Report the results of the vital signs to the nurse. 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. 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. Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? - Assess for bladder distention. A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. Which action should the nurse take? - Commend the client for selecting a high biologic value protein. When evaluating a client's 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. 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. 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. 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 vitamin and mineral supplements do you take?"

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? - After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube. 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. Which is the best response to this client's silence? - "It is OK if you don't want to talk about your surgery. I will be available when you are ready." A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? - Mix each medication individually. A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV every 24 hours 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. 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 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. 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. 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 Sims' position with the client's weight on the anterior ilium.

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's receptors adapt over time as they are exposed to heat." 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? - Tell the surgeon that the brother-in-law will decide after explanation of the proposed surgery is provided to him and the widow. 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 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 administration of analgesics. 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 prohibited. The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? - Inherited familial health disorders. A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.) - 1 Docusate sodium (Colace) 0.3 grams is prescribed for a client who has frequent constipation. Each capsule contains 100 mg. How many capsules should the nurse administer? - 3

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A 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." 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. 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? - Move the chair parallel to the right side of the bed, and stand the client on the right foot. A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups. The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is available as 5 mg/5 ml. A measuring device marked in teaspoons is being used. How many teaspoons should the nurse administer? - 2 An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings through a gastrostomy tube (GT). What is the best position for the client for administration of the bolus tube feedings? - Fowler's. Secobarbital (Seconal) 150 mg is prescribed at bedtime for a male client who is scheduled for surgery in the morning. The scored tablets are labeled 0.1 gram/tablet. How many tablets should the nurse administer? (Enter the numerical value only. If rounding is required, round to the nearest tenth.) - 1.5 The nurse is developing a plan of care for a client with dementia. Which feature of confusion in the elderly is accurate? - Disorientation often follows relocation to new surroundings.

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. 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? - "I will limit my intake of beef to 4 ounces per week." When conducting an admission assessment, the nurse should ask the client about the use of complementary healing practices. Which statement is accurate regarding the use of these practices? - Many complementary healing practices can be used in conjunction with conventional practices. A female client asks the nurse to find someone who can translate her treatment concerns into her native language. Which action should the nurse take? - Request and document the name of the certified translator. 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. 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. 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-release capsules are not available, which dosing schedule should the nurse advise the client to follow? - 8 a.m., 4 p.m., and midnight. The nurse is examining a male client who reports itching on his right arm, The nurse observes a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? - Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.

The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How many tablets should the nurse plan to administer? - 1 1/2 tablets. 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. 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. 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. Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? - Upper arm circumference. Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? - Examining a chest x-ray obtained after the tubing was inserted. 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. A male client with obesity discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 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 examination before beginning your planned exercise program."

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An older 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. The nurse is evaluating a 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, vanilla ice cream. A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? - Nutritional history. An older 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. 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 administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, which action should the nurse take next? - Flush the tube with water. Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? - Chocolate pudding. A client's spouse is learning passive range-of-motion for the client's contracted shoulder. The nurse observes that the spouse is holding the client's arm above and below the elbow. Which nursing action should the nurse implement? - Acknowledge that the spouse is supporting the arm correctly. 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.

Which action is most important for the nurse to implement when donning sterile gloves? - Keep gloved hands above the elbows. The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler- delivered medication to demonstrate correct use of the inhaler? - During the inhalation. A client is receiving alprazolam (Xanax) 0.75 mg PO bid for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only.) - 1.5 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. A client's daily PO prescription for aripiprazole (Abilify) is increased from 15 mg to 30 mg. The medication is available in 15 mg tablets, and the client already received one tablet today. How many additional tablets should the nurse administer so the client receives the total newly prescribed dose for the day? (Enter numeric value only.) - 1 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. Which action should the nurse take first? - Reposition the client on her side. 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. 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.

HESI Fundamentals Practice Exam 2023 to 2024

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