hesi fundamentals rn exit v1test bank qampa 2versions
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HESI FUNDAMENTALS RN EXIT V1TEST BANK Q&A( 2VERSIONS)
1. Wheezing is often associated with asthma- assess breathing patterns and learnabout
any precipitating factors that caused the onset of the wheezing
2. A male client with limited mobility is discharged with home health services. Whenthe
home health nurse arrives, the client asks what he does for the swelling in hisleg.
Which should the nurse implement?
✔ -instruct the client to flex both of his feet several times a day
3. A client at an outpatient clinic submits a clean-catch midstream urine specimenfor a
routine urinalysis. In later review of the client’s medical record, which dataindicates to
the nurse that the specimen collection should be repeated?
✔ -the urine specimen shows multiple organisms in low colony counts
Rationale: *often indicates that a contaminated specimen was obtained
4. During the admission assessment of a terminally ill male client, the client statesthat he
is an agnostic. What is the best nursing action in response to this statement?
✔ -document the statement in the client’s spiritual assessment
5. The nurse observes a newly admitted older adult female take short stems andwalk very
slowly while pushing a walker in front of her. What action should thenurse take in
response to these observations?
✔ -complete a full fall risk assessment of the client
6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vitalsigns
should the nurse obtain first?
✔ -respiratory rate
Rationale: *cyanosis is a bluish discoloration, an indication of
hypoxemia
7. A middle-aged male client tells the nurse that two weeks ago he began exercising four
times a week to lose weight and to help him sleep better. He states that it still takes
him an hour to fall asleep at night. Which action should thenurse implement?
✔-ask the client to describe the exercise schedule that he has been
following
Rationale: *to determine if he is exercising too close to bedtime
8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen
saturation remains at 94%, which is the same reading obtained prior tostarting the
procedure. What action should the nurse take in response to this finding?
✔-complete the intermittent suction of nasopharynx *suctioning can be
continued if the client’s oxygen saturation remains above 90% or
does notdecrease 5% from the initial baseline
9. An older male client returns to the clinic for chronic pain management after taking
morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication
only when the pain was too severe to sleep. What action should the nurse implement?
, ✔-instruct the client to take the MS Contin every 12 hours as prescribed
10.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
requests a change in assignment, stating she has not yet been fitted fora particulate
filter mask. What action should the nurse take first?
✔ -instruct the UAP that a standard face mask is sufficient for the
provision of care for the assigned client
Rationale: *a particulate filter mask is indicated for clients with
airborneprecautions
11.The community health nurse is making a home visit when the client, who is sittingat the
kitchen table, begins to have a seizure. What action should the nurse take first?
✔ -assist the client to the floor
12.A client is in contact isolation due to a 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 ordershould the nurse perform the interventions?
✔-restart the IV, perform tracheostomy care, change the coccyx
dressing
13.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?
✔-Potassium 3.1 mEq/L (3.1 mmol/L)
14.A client diagnosed with primary open-angle glaucoma received a prescription formiotic
eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to
include in the client’s teaching?
✔ - “do not allow the dropper bottle to touch the eye”
15.*Sleeping side
✔ lying with hips and knees flexed prevents unnecessary pressure on
support muscles, ligaments, and lumbosacral joints and reduces low
backpain
16.*Obesity
✔ a BMI greater than 30
17.*Hygiene self-care deficit
✔ evaluate the client’s participation in self-care to optimal level of
capacity isthe best goal to evaluate progress in recovery
18.The unlicensed assistive personnel (UAP) describes the appearance of thebowel
movement s of several clients. Which descriptions warrant additionalfollow-up by
the nurse?
✔ -multiple hard pellets, tarry appearance, and brown liquid
,19.A client with a gastronomy tube is recovering a continuous feeding, and the nurse
suspects that the client has aspirated some of the feeding. What is theaction by
the nurse?
✔ -stop the tube feeding and assess the client
20.*it is the best response for the nurse to provide a response that reflects what theclient
stated and confirms their condition is serious.
21.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 safelyto dry his feet.
While drying the client’s feet, the nurse should emphasize the need to thoroughly dry
which area of the feet?
✔ -between the toes
22.When performing blood pressure measurement to assess for
orthostatic hypotension, which action should the nurse implement
first?
✔ -position the client supine for a few minutes
23.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 the nurse contact?
✔-a daughter-in-law designated as the client’s Durable Power of
Attorney
(DPOA)
24.A 24-hour urine specimen is being collected for analysis of creatinine clearance.After
explaining the procedure, the client tells the nurse that the first sample is inthe urinal.
When discarding this specimen, what action should the nurse take?
✔-check the sample’s pH and specific gravity
25.A client has begun a long-term maintenance therapy with lithium, which has anarrow
therapeutic index. Which adverse effect is most important for nurse toinclude in the
teaching plan?
✔-toxicity
26.A postoperative client has three different PRN analgesics prescribed for differentlevels
of pain. The nurse inadvertently administers a dose that is not within the prescribed
parameters. What action should the nurse take first?
✔ -assess for side effects/adverse effects of the medication
27.Which landmarks are useful to the nurse when administering an
intramuscularinjection in the ventrogluteal site?
✔ -the greater trochanter and anterior superior iliac spine
28.To assess the quality of an adult client’s pain, what approach should the nurseuse?
✔ -ask the client to describe the pain
, 29.The home health nurse is reviewing the personal care needs of an elderly client who
lives alone. Which client assessment findings indicate the need to assign anunlicensed
assistive personnel (UAP) to provide routine foot care and file the client’s toenails?
(Select all that apply)
✔ -diminished visual activity
✔ syncope (dizziness) when bending
✔ hand tremors
30.The nurse measures the client’s blood pressure (PB) and notes that it is significantly
higher than the previous reading. What should the nurse do next?(Select all that
apply)
✔ -retake the client’s blood pressure in the opposite arm, determine
the client’s activity and feeling prior to the BP measurement
31.A male Native American presents to the clinic with complaints of frequent abdominal
cramping and nausea. He states that he has chronic constipation andhad not had a
bowel movement in five days, despite trying several home remedies. Which
intervention is most important for the nurse to implement?
✔assess for the presence of an impaction
Rationale: *it is common for cultures, such as Native Americans, to
believe in using home remedies and herbs before seeking medical
attention. The herbalremedies used for constipation and nausea
32.A client is admitted with pneumonia and has a recent history of methicillin-
resistant Staphylococcus aureus (MRSA). The client is placed
inisolation. While caring for the client, which item should the nurse
place in adesignated biohazard bag before it is removed from the
room?
✔ -paper mask and gown
33.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 deep vein thrombosis and is allergic to latex.
When removing the adhesive bandages, the nurse observes skinredness surrounding
the dressing wound. What action should the nurse implement?
✔ -replace dressing with cotton pads and silk tape
Rationale: *the skin redness surrounding the wound may be due to
latex inthe adhesive bandages, so the bandage should be replaced
with non-latexdressing, such as cotton pads and silk tape. A culture
is not indicated. A topical antibiotic ointment may be used if the
wound appears infected, but is not indicated for inflammatory
redness created by the latex dressing.
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