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HESI RN FUNDAMENTALS EXAM 2018 A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administer a dose that is not within the ... prescribed parameters. What action should the nurse take first? A) Determine if the pain was relieved. B) Complete a medication error report. C) Assess for side effects of the medication. D) Document the clients responses. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) A) Multiple hard pellets. B) Brown liquid. C) Formed but soft. D) Solid with red streaks. E) Tarry appearance. An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? A) The importance of using vaginal lubricants. B) Methods used to practice safe sex. C) Information about alternative ways to express sexuality. D) Intercourse positions that help prevent tears. A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit In a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take? A) Have the client put both arms around the nurse’s neck for support. B) Place the wheelchair on the client’s left side. C) Instruct the client to look at his feet. D) Instruct the client total slow, deep breaths while transferring. The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A) Complete a full fall risk assessment of the client. B) Teach the client to take longer steps at faster pace. C) Suggest that the the client use a wheelchair instead of a walker. D) Place client on bedrest until the healthcare provider is notified. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse administer? (Round to the nearest tenth.) While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? A) Reposition the pulse oximeter clip to obtain a new reading. B) Stop suctioning until the pulse oximeter reading is above 95%. C) Complete the intermittent suction of the nasopharynx. D) Apply an oxygen mask over the client’s nose and mouth. An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A) Discuss with the client her meaning of heroic measures. B) Obtain a “do not resuscitate” (DNR) prescription. C) Set up a family conference to discuss the client’s. D) Consult the palliative care team about client’s care. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching A) “Do not allow the dropper bottle to touch the eye.” B) “Administer the medication directly on the cornea.” C) “Squeeze your eye closed after administering the drops.” D) “Wash your hands after each administration of eye drops.” When assessing a client who starts to wheeze related data should obtain? A) Presence of radiation. B) Heart sounds. C) Body temperature. D) Precipitating factors. The home health nurse is reviewing the personal care of an elderly client who lives alone.Which client assessment findings indicate the need to assign an unlicensed assistive personnel. (UAP) to provide routine foot care and file the client’s toenails? Select all that apply.) A) syncope when bending. B) Hand tremors. C) Diminished visual acuity. D) Urinary incontinence. E) Shuffling gait. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client’s risk for infection related to the catheter? A) Flush the catheter daily with sterile saline. B) Encourage increased intake of oral fluids. C) Administer a PRN antipyretic if a fever develops. D) Secure the drainage bag at bladder level during transport. To assess the quality of an adult client’s pain, what approach should the nurse use? A) Observe body language and movement. B) Provide a numeric pain scale. C) Ask the client to describe the pain. D) Identify effective pain relief measures. A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide? A) “That’s correct, you do not have long to live” B) “Would you like me to call your minister?” C) “Don't give up, you still have chemotherapy to try.” D) “Yes, your condition is serious.” When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A) Apply the blood pressure cuff securely. B) Record the client’s pulse rate and rhythm. C) Position the client supine for a few minutes. D) Assist the client to stand at bedside. A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP request a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take? When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A) Modify the nursing interventions to achieve the clients goals. B) Determine if the expected outcomes were realistic. C) Review related professional standards of care. D) Obtain current client data to compare with expected outcomes. A policy requiring the removal of acrylic nails by all nursing personnel was implemented six months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? A) Number of the staff-induced skin injuries. B) Client satisfaction survey. C) Rate of needlestick injuries by nurses. D) Healthcare-associated infection rates. A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assisstive personnel (UAP) who assissting with client’s care? (Select all that apply.) A) Instruct the client about signs of orthostatic hypertension B) Determine if the client needs to have a gait belt applied C) Measure the clients vital signs before the client walks. D) Offer to assist the client to void prior to walking in the hall. E) Report the onset of any dizziness or light headedness. A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for nurse to include in the teaching plan? A) Dependence. B) Toxicity. C) Interaction. D) Tolerance. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? A) The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace. B) Completing the electronic record during an interview is a legal obligation of the examining nurse. C) The nurse has limited ability to observe nonverbal communication while entering the assessment electronically. D) The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should nurse contact? A) The client’s oldest living child, a lawyer, who is visiting from out of town. B) A daughter -in-law designated as the client’s Durable Power of Attorney (DPOA). C) The client’s youngest son, identified by family members as the family spokesperson. D) The client’s spouse who lives in the independent living unit of the facility. A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions? A) Change coccyx dressing, perform tracheostomy care, restart the IV. B) Perform tracheostomy care, change coccyx dressing, restart the IV. C) Restart the IV, perform tracheotomy care, change coccyx dressing. D) Change coccyx dressing, restart the IV, perform tracheostomy care. What self-care outcome is best for the nurse to use in evaluating a client’s recovery form a stroke that resulted in left-sided hemiparesis? A) Promote independence by allowing client to perform all self-care activities. B) Participates in self-care to optimal level of capacity. C) Client verbalizes importance of hygienic practices in the recovery process. D) Self-care needs to be completed by the unlicensed assistive personnel. A female client’s significant other has been at her bedside providing reassurance and support for past 3 days, as desired by the client. The client’s estranged husband arrives and demands the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? A) Communicate the client’s wishes tall members of the multidisciplinary team. B) Encourage the client to speak with her husband regarding his disruptive behavior. C) Request a consultation with the ethics committee for resolution of the situation. D) Obtain a prescription from the healthcare provider regarding visitation privilages. The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement? A) Decrease the flow rate to 1 L/minute. B) Discontinue the use of the nasal cannula. C) Apply lubricant to the cannula tubing. D) Place padding around the cannula tubing. A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement? A) Ask a Spanish speaking staff member to talk with the family. B) Use a Spanish translation reference to interview the family. C) Close the door to client’s room to provide family privacy. D) Sit quietly with the family to offer comfort and support. The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented? A) Apply a hydro gel (Duaderm) dressing B) Increase the frequency of the dressing changes. C) Replace the gauze with transparent dressing. D) Leave the dressing off until consulting with the healthcare provider. The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.) A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his legs. Which should nurse implement? A) Encourage the client to take short walks around the block. B) Explain the need to keep the head of the bed elevated. C) Advise the client to dangle his feet during meals and before bedtime. D) Instruct the client to flex both of his feet several times a day. The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the draining wound. What action should the nurse implemented? A) Replace dressing with cotton pads and silk tape. B) Measure and compare ankle-brachial pressure index. C) Obtain sample of the drainage for culture. D) Apply an antibiotic ointment to the wound. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply.) A) Retake the client’s blood pressure in the opposite arm. B) Ask another nurse to assist in assessing for an apical-radial pulse deficit. C) Assign the unlicensed assistive personal to recheck the BP in an hour. D) Immediately take 2 more readings on the same arm. E) Determine the client’s activity and feelings prior to the BP measurement. A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room? A) The nurse’s stethoscope. B) Paper mask and gown. C) Bed linens D) A sputum. A middle-aged male client tells the nurse that has weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement? A) Advice the client that lifestyle changes often take several weeks to be effective. B) Determine the amount of weight the client has lost since increasing his activity. C) Encourage the client to exercise every day to eliminate bedtime wakefulness. D) Ask the client to describe the exercise schedule that he has been following. Which landmarks are useful to the nurse when administering an intramuscular injection in ventrogluteal site? A) The greater trochanter and anterior superior iliac spine. B) The knee and greater trochanter. C) The upper, outer quadrant of the buttock. D) The deltoid muscle. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has chronic constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the nurse to implement? A) Determine what home remedies were used. B) Assess for the presence of an impaction. C) Obtain list of prescribed home medications. D) Evaluate stool sample for presence of blood. What information is most important for the nurse to obtain in determining a client’s need for referral for obesity counseling? A) Body weight 10% over ideal body weight. B) Body mass index greater than 35. C) Daily caloric intake of 3500 calories. D) Client’s expressed desire to lose 50 pounds. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with client. When the family leaves, what action should the nurse take first? A) Apply the restraints to maintain the client’s safety. B) Reassess the client to determine the need for continuing restraints. C) Document the time the family left and continue to monitor the client. D) Call the healthcare provider for a new prescription. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider? A) Potassium 3.1mEq/L (3.1 mmil/L) B) Sodium 142 mEq/L (142 mmol/L) C) Total calcium 9.2 mg/dl (2.3 mmol/L) D) Chloride 98 mEq/L (98 mmil/L) The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet? A) Between the toes. B) Around the ankles. C) On dorsal surfaces D) Over the heels. A 24-hour urine specimen is being collected for analysis clearance. After explaining the procedures, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take? A) Initiate the collection the foll [Show More]

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