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HESI Fundamentals
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, back surgery for a herniated intervertebral disk, and reports that she has found
acupuncture effective in resolving past acute episodes. Which response is best for
the nurse to provide?
a. Surgery removes the disk and is the only treatment that can totally resolve the pain
b. The medication regimen you previously used should be re-evaluated for dose adjustment
c. Massage and hot pack treatments are less invasive and can provide temporary relief
d. Acupuncture is a complementary therapy that is often effective for management of pain
26. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription
states “clean the wound and then apply collagenase.” collagenase is a debriding agent. The prescription does not specify a cleaning method.
Which technique should the nurse cleanse the pressure ulcer?
a. Lightly coat the wound with povidone-iodine solution
b. Irrigate the wound with sterile normal saline
c. Flush the wound with sterile hydrogen peroxide
d. Remove the eschar with a wet-to-dry dressing
27. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
a. Document the client’s circadian rhythms
b. Assess for flushed, warm skin regularly
c. Measure temperature at regular intervals
d. Vary sites for temperature measurement
28. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?
a. Position the client supine for a few minutes
b. Assist the client to stand at the bedside
c. Apply the blood pressure cuff securely
d. Record the client’s pulse rate and rhythm
29. The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving
hydromorphone 3 mg IM 6 hours PRN severe pain. How many mL should the nurse administer to the client? (Enter the numerical value
only. If rounding is required , round to the nearest tenth) Ans: 0.8
30. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description
warrants additional follow up by the nurse? (select all that applies).
a. Solid with red
streaks.
b. Brown liquid.
c. Multiple hard pellets.
d. Formed but
soft.
e. e. Tarry
appearance.
31. A female 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...she has not yet been fitted for a particulate filter mask.Which action should the nurse take?
a. Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before
providing personal care
b. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
c. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
d. Before changing assignments, determine which staff members have fitted particulate filter masks
32. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client
verbalizes concerns about pain. What action should the nurse implement?
a. Explain the respiratory problems that can occur with morphine use.
b. Teach family how to evaluate the effectiveness of analgesics.
c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump.
d. Provide client with a schedule of around-the-clock prescribed analgesic use.
33. What assessment finding places a client at risk for problems associated with impaired skin integrity?
a. Scattered macula of the face
b. Capillary refill 5 seconds
c. Smooth nail texture
d. Absence of skin tenting
34. 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. Determine if the expected outcomes were realistic
b. Obtain current client data to compare with expected outcomes
c. Modify the nursing interventions to achieve the client’s goals
d. Review related professional standards of care
35. The nurse 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 reading?
a. BP 142/88 mmHg
b. 2+ edema of fingers and hands
c. Radial pulse volume is +3
d. Capillary refill time is 2 seconds
36. 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 the 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.
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