HESI Fundamentals Final Exam with Rationales Graded A 2023

An elderly client fractured his hip as a result of a fall at home. Because of his extensive cardiac history and chronic obstructive pulmonary disease, surgery isn't an option. The client tells the nurse he doesn't know how he's going to get better. Which response is best? a) "You're doing fine." b) "What is your biggest concern right now?" c) "Give it some time and you'll be OK." d) "You don't believe you're doing well?" - b Open-ended questions allow a client to control what he wants to discuss and help a nurse determine care needs. Telling the client that he's fine or that he just needs more time doesn't encourage him to verbalize his concerns. Reiterating the client's concerns may not encourage him to verbalize his feelings A student nurse requires additional teaching if which of the following factors is identified as contributing to a client's Risk for infection? a) Proper nutrient intake b) Impairment of primary body system defenses c) Chronic disease d) Inadequate secondary defenses - Proper nutrient intake Explanation: Malnutrition, rather than proper nutrient intake, would put the client at risk for infection. Inadequate secondary defenses, impaired primary defenses, and chronic disease put the client at risk by lowering the body's ability to fight infection. The nurse assesses an older adult for signs of dehydration. Which findings would be consistent with a diagnosis of dehydration? a) orthostatic hypotension b) moist crackles c) bounding pulse d) shortness of breath - orthostatic hypotension Correct Explanation:Orthostatic hypotension or persistent hypotension is present in dehydration, as are poor skin turgor, dry oral mucous membranes, and tachycardia. If the dehydration is severe, the client may also be restless, confused, and thirsty. Most instances of crackles is indicative of excess fluid volume, not dehydration. Shortness of breath or a bounding pulse may be indicative of excess fluid, not dehydration. The nurse is planning care with the parents of a child who requires continuous peritoneal dialysis. Which finding should be discussed with the health care provider (HCP)? a) The child reports having a previous surgery for a ruptured appendix. b) The family lives a long distance from the medical facility. c) The family feels the child cannot self-regulate to wake at night and change bags. d) The child attends a large public school. - The child reports having a previous surgery for a ruptured appendix. Explanation: A client who has had a ruptured appendix may have peritoneal scarring that may alter the effectiveness of treatment. Living a long distance from a medical facility is typically a reason to select peritoneal dialysis. Attending a large school is not a problem, but the school nurse needs to be included as part of the health care team. Typically the treatment schedule can be planned to allow for uninterrupted sleep at night. A nurse is performing an admission assessment on a client newly admitted to the hospital and has documented the client as being a member of the Native American subculture. A subculture is best described as which of the following? a) A cultural group with fewer than 5 million members in the United States. b) A unique cultural group that exists within the larger culture. c) A cultural group with values that are incongruent with those of the dominant culture. d) A unique cultural group with unspecified geographic origins. - A unique cultural group that exists within the larger culture. Correct Explanation:Subcultures are unique cultural groups that coexist within the dominant culture of the United States. Subcultures are not defined according to the size of their membership or the lack of specific geographic origins. Subcultures may have some values that differ from those of the dominant culture, but this is not their defining characteristic. A nurse reports to the hospital occupational health nurse (OHN) that he/she was splashed with blood during the resuscitation of an HIV-positive client. The nurse asks the OHN when he/she will know whether he/she is positive or negative for HIV infection. Which of the following is the most appropriate response by the OHN? a) "The test results will vary during the first year of testing for the disease." b) "We will test you in 4 weeks, and then we will have a definitive answer." c) "Accurate results will be obtained by testing at 3 months and again at 6 months." d) "Most nurses who have been splashed do not test positive if they wash immediately." - "Accurate results will be obtained by testing at 3 months and again at 6 months." Correct Explanation: Ninety-five percent of exposed individuals will seroconvert within 3 months; 99% will convert by 6 months. The other options do not accurately reflect the timeline for seroconversion following exposure. Which would be most helpful when coaching a client to stop smoking? a) Review the negative effects of smoking on the body. b) Explain how smoking worsens high blood pressure. c) Discuss the effects of passive smoking on environmental pollution. d) Establish the client's daily smoking pattern. - Establish the client's daily smoking pattern. Correct Explanation: A plan to reduce or stop smoking begins with establishing the client's personal daily smoking pattern and activities associated with smoking. It is important that the client understands the associated health and environmental risks, but this knowledge has not been shown to help clients change their smoking behavior.A client presents to the OB triage unit with no prenatal care and painless bright red vaginal bleeding. Which interventions are most indicated? a) applying an external fetal monitor and completing a physical assessment b) obtaining a fundal height assessment on the client c) applying an external fetal monitor and performing a sterile vaginal examination d) obtaining fundal height and performing a sterile vaginal examination - applying an external fetal monitor and completing a physical assessment Explanation: Bright red vaginal bleeding without contractions could indicate a placenta previa. A sterile vaginal exam should never be done on a woman with a known or suspected placenta previa. Applying the external fetal monitor will allow the nurse to assess fetal status. A complete physical assessment of the client is indicated. A fundal height is used to monitor fetal growth during pregnancy but does not provide information related to vaginal bleeding.