HESI FUNDAMENTALS Examinable Questions with accurate answers, RATED A. 2022/2023

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HESI FUNDAMENTALS Examinable Questions with accurate answers, RATED A. 2022/2023 1. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by... a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." 2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Absent bowel sounds with distention 3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Temperature 4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administe analgesics to the child on a routine schedule throughout the day and night. 5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub 6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." 7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15 min. lOMoARcPSD|499 043 4 8. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change 9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Temporal 10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The signature on the preoperative consent form is the client's 11. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment 12. A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes with her hands held higher than her elbows 13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Second intercostal space to the right of the sternum 14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart 15. A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? "What worries you about being without your teeth?" 16. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Encourage the client to express his thoughts about death and dying lOMoARcPSD|499 043 4 17. A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? "Tell me what I can do to help you overcome your fear of giving yourself injections." 18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness 19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Screening groups of older adults in nursing care facilities for early influenza manifestations 20. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Perform hand hygiene 21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh 22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers 23. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 24. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Sit on the toilet 30 minutes after eating a meal." 25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Obtain client information lOMoARcPSD|499 043 4 26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Place the wheelchair at a 45 degree angle to the bed 27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation 28. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Remove the restraints one at a time 29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Sit and hold the client's hand 30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "I keep having nightmares about my upcoming surgery." 31. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspect, Auscultate, Percuss, Palpate 32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining cotton balls for the tracheostomy care 33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses 34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Notify the provider about the client's decision lOMoARcPSD|499 043 4 35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? Donate autologous blood before the surgery 36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client reports severe pain 37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "Using a cuff that is too small will result in an inaccurately high reading." 38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Carefully remove the gloves and follow with hand hygiene 39. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher 40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Raise the level of the bed 41. A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action? Check the client's perineum 42. A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as: Purulent 43. A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of: lOMoARcPSD|499 043 4 Solutes in the urine 44. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should: Cleanse the entry port priot to withdrawing urine. 45. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient? I am going to listen to your abdomen 46. A nurse is caring for a client who is post-op following a partial colectomy. THe patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time? When the GI tract is working again, in about three to five days, the tube can be removed. 47. A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces? Oil Retention 48. When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take? Notify the surgeon. 49. A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should: Offer the client tart or sour foods. (This makes it easier for them to swallow) 50. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to: Establish an airway 51. A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? 100% oxygen via partial rebreathing mask lOMoARcPSD|499 043 4 52. A client is hospitalized for an infection of a surgical wound following abd surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of: Vitamin C and Zinc 53. When communicating with a client who is hearing impaired, the nurse should Face the client and speak slowly 54. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take Examine the elbow 55. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client: Is unable to swallow foods by mouth 56. CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to: Push hard and deep on the chest 57. A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device? Collapsing the device whenever its 1/2-2/3 full of air. 58. A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan? Demonstration of appropriate hand hygeine 59. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should Weight the client upon rising. 60. A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse: Refrigerates the collected specimen 61. When replacing a client's surgical dressing, the nurse should: Don clean gloves to remove the old dressing 62. A nurse is preparing to instert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first? Explain the procedure to the client. [Show More]

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