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HESI FUNDAMENTAL TESTBANK (Questions & Answers)
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HESI FUNDAMENTAL TESTBANK (Questions & Answers)Hesi fun test help
V1- 54 QUESTIONS
Policy of removal of acrylic nails-
Health care-associated infection rate
Assist a newly admitted client with personal hygiene measures. The client gag reflex
Place tongue blade on back half of tongue
Older adult male procedure for collecting 24 h urine for creatinine clearance
Empty the urinal contents into the 24 h collection container
54 year old and his wife informed of his terminal cancer
Refer her to support group for family members of those dying of cancer
Client body mass index (BMI) of 30, initial approach to weight loss plan
Keep a record of food and drinks consumed daily
Client has nasal cannula delivering oxygen at 2 L/min. assess skin damage related to cannula search for
areas
Top of ears, around the nostrils, over the cheeks
Observes an UAP providing a total bed bath for a confused and lethargic client. The UAP soaking client
food in a basin of warm water
Remind the UAP to dry between the client toes completely
Colleague viewing electronic health record (HER) of a client who holds an elected position. Client is not
part of colleague assignment.
Communicate the colleague action to unit charge nurse
At 0100 male client second postoperative night, client is unstable to sleep and plan to read until feeling
sleepy
Bring the client PRN sedative-hypnotic
Cardiovascular intensive unit creating continuous quality project addresses coronary artery disease
(CAD). Action to protect client privacy
Remove identifying information of the clients who participated
A male client with unstable angina needs cardiac catheterization. Nurse presents consent form for
signature, client hesitates and ask how wires will keep his heart going
Postpose the procedure until the client understand risk and benefits
How to do active range of motion (ROM). To exercise the hinge joints
Bend the arm by flexing the ulnar to the humerus
Three different PRN analgesics prescribed for different levels of pain. Nurse inadvertently administers
dose that is not within the prescribed parameters
Access for side effects of medication
Client is fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias. Lab values to validate existence
Hypokalemia
Significant other has been at her bedside providing reassurance and support for past 3 days, client
estranged husband arrives and demands that the significant other not be allowed to visit
Request a consultation with the ethics committee for resolution of the situation
Client is using accessory neck muscles during respirations. Follow-up action should the nurse take first
Check for neck vein distention
Location should the nurse select to administer a 3 ml IM injection
Ventrogluteal
Client with hypernatremia?
Review food labels for sodium content
,Changing a client post-operative dressing, observe a red swollen wound with a moderate amount of
yellow and green drainage and foul odor. There is a positive MRSA, most important action
Initiate contact precautions
Potential side effects of newly prescribed med,
Assess the client for health alterations that may be impacted by the effects of the med
2 days post-op from thoracic surgery and is complaining of incisional pain. Client has received pain meds
2 h ago.
Instruct the client to use guided imagery and slow rhythmic breathing
Furosemide 40 mg BID. Pharmacy provides 20 mg Tab. How many each day
4 tablets
Medical unit following a fall at home. When undressing, he is wearing adult diaper and skin breakdown
is obvious over his sacral area
Determine the size and depth of skin breakdown over the sacral area
Nurse record the assessment in the electronic health record. Most acute during electronic
documentation
The nurse has limited ability to observe nonverbal communicate while entering the assessment
electronically
Client with chronic back pain has been taking muscle relaxants and analgesics to manage discomfort,
now experiencing an acute episode of pain that is not relieved. Back surgery for herniated intervertebral
disk, acupuncture help past acute episode
Acupuncture is complementary therapy that is often effective for management of pain
Wound care to stage 3 pressure ulcer that has a large amount of eschar. Clean wound then apply
collagenase.
Irrigate the wound with sterile normal saline
Client is admitted for fever of unknown origin. Assess fever patterns
Measure temperature at regular intervals
Perform BP measurement to assess orthostatic hypotension
Position the client supine for a few minutes
Hydromorphone 4 mg/dl from Pyxis med station, an automated dispending system, 3 mg IM 6 hours PRN
severe pain
0.8
unlicensed assistive personnel (UAP) describes the appearance of the bowel movement. Description
warrants additional follow up
Solid with red, Streaks Brown liquid, multiple hard pellets. Tarry appearance
Female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions
UAP requests a change in assignment
Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this
client
In-home hospice care is arranged for a client with stage 4 lung cancer. Palliative nurse is arranging for
discharge, the client verbalizes concerns about pain
Provide client with a schedule of around-the-clock prescribed analgesic use
Assessment finding places a client at risk for problems associated with impaired skin integrity
Capillary refill 5 seconds
Evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes
identified in the plan of care
Determine if the expected outcomes were realistic
, Attaches a pulse oximeter to a client’s fingers and obtains an oxygen saturation reading of 91%. Which
assessment finding. Most likely contributes to this
2+ edema of fingers and hands
Hospitalized client who was placed in restraints due to confusion. The family removes the restraints
while they are with the client
Reassess the client to determine the need for continuing restraints.
Is charging an adult woman who was hospitalized for 6 days for treatment of pneumonia. the client
appears anxious
Instruct the client to repeat the medication plan
Nurse provide for an UAP caring for a client with MRSA who has a prescription for contact precautions
Don a gown and gloves when entering the return
Suctioning a client’s nasopharynx the nurse observes that the client’s oxygen saturation remains at 94%,
same reading
Complete the intermittent suction of the nasopharynx
UAP has lowered the head of the bed to change the lines for a client who is bed less. Which
observation...most immediate intervention
Purulent drainage is present around the insertion site of the feeding tube
A male client presents to the clinics stating that he has a high stress job and is having difficulty falling
asleep at night.
Teach coping strategies to use when feeling stressed
Nurse is teaching a client about use of the syringes and needles for home administration of medications.
Which action by the client indicates an understanding of standard precaution?
Washes hands before handling the needle and syringe
UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is
placing soft pillows along the side rails.
Assume responsibility for placing the pillows while the UAP complete another task
Cerebrovascular accident is placed on a ventilator. The client’s daughter arrives with a durable power of
attorney, and a living will
Notify the healthcare provider
An elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the
hallway outside her room
Provide space and privacy for the family to share their concerns about the client’s discharge
Client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists
The ability to perform ADLs
Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He
states that the chronic constipation and had not had a bowel movement in five days
Determine what home remedies were used
Assessment data reflects the need for the nurses to include the problem, “Risk for falls” in a client’s plan
of care
Opioid analgesic received one hour ago
An indwelling urinary catheter has an output of 150 mL, previous 6 hour shift
Review the intake and output record
Scheduled to deliver a baby by C-section in the next 24 hours
Rely on cultural norms as the basis for providing nursing care for this client
Admission assessment of a terminally ill male client that he is an agnostic
Document the statement of the client’s spiritual assessment
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