1. Aclient at an outpatient clinic submits a clean- catch midstream urine
specimen for a routine urinalysis. In later review of the client's medical
record,whichdataindicatestothenursethatthespecimencollectionshould be
repeated?
A. Theurinespecimenshowsmultipleorganismsinlowcolonycounts.
B. Theclientreportedeating amealbeforevoidingtheurinespecimen
C. Therewasa totalof30mlofurinevoidedintothespecimencup
D. Themedicalrecordindicatestheclientisallergictomostantibiotics
2. Whenassessingaclientwhostartstowheezewhichrelateddata
should the nurse obtain?
A. Precipitatingfactors
B. BodyTemperature
C. Presenceof radiation
D. Heart sounds
3. Aclientdiagnosedwithprimaryopen-angleglaucomareceiveda
prescription for miotic eye drops, pilocarpine HCl (Pilocarpine).What
instructions should the nurse plan to include in this client’s teaching?
A. “Administerthemedicationdirectlyonthecornea.”
B. “Washyourhandsaftereachadministrationofeyedrops.”
C. “Donotallowthedropperbottletotouchtheeye.”
D. “Squeezeyoureyeclosedafteradministeringthedrops.”
4. Thenurseobservesthatamaleclientonaclearliquiddiethasacup of
coffee on his breakfast tray. What action should the nurse implement?
A. Consultwiththedieticiantolearniftheclientisallowedtodrink coffee
B. Determinewhichmemberofthenursingstaffbroughtthecupofcoffee to the
client
C. Remindtheclientthatnomilk,orcreamercanbeaddedtothecoffee.
,HESI RN FUNDAMENTALS EXAM | 3 VERSIONS COMBINED
LATEST 2023 GRADED A+
D. Removethecoffeefromthetray,advisingtheclientthatitisnot
included in the diet.
5. Whenevaluatingtheeffectivenessofaclient’snursingcare,thenursefirst
reviews the expected outcomes identified in the plan of care. Whataction
should the nurse take next?
A. Determineiftheexpectedoutcomeswere realistic
B. Modifythenursinginterventionstoachievetheclient’sgoals
C.Obtaincurrentclientdatatocomparewithexpectedoutcomes
D.Reviewrelatedprofessionalstandardsof care.
6. The nurse learns that members of the nursing staff are uncomfortable
with responding to client family members who are angry. In designing a
teachingsessiontohelpthestaffrespondmoreeffectivelyinthesesituations, which
instructional strategy is best for the nurse to use?
A. Return demonstration
B. Journaling
C. Analogies
D. Role playing
7. Thenurseobservestheskin overa client'sgreatertrochanterasseen in
thepicture.Whatactionsshouldthenurseimplement?(selectallthat apply)
A. Removetheescharbeforeapplyingandsecuringahydrocolliod
B. Preparetoimplement apressureredistributionmattress
C. Obtainaspecimenofthesite forcultureandsensitivity
D. InstructtheUnlicensedassistivepersonneltofrequentlyofferoralfluids
E. Explaintotheclientthatthewoundneedsdebridement
8. The nurse has removed the barbiturate capsule from the unit dose
wrappertoadministertoamaleclient.Theclientdecideshewantstowatcha
television program and requests not to take the medication. Which action
should the nurse implement?
A. Creditthemedicationbackandputintheclient’smedicationbox
B. Keepthemedicationandseeifthe clientwillwanttotakeitlater.
,HESI RN FUNDAMENTALS EXAM | 3 VERSIONS COMBINED
LATEST 2023 GRADED A+
C. Haveanothernursewatchdisposalofthemedicationintodispo
sal container
D. Explainthatsincethemedicationisacontrolledsubstanceitmustbe taken.
9. The home health nurse is reviewing the personal care needs of an
elderly client who lives alone.Which client assessment findings indicate the
needtoassignanunlicensedassistivepersonal(UAP)toprovideroutinefoot care
and file the client’s toenails? (Select all that apply).
A. Shuffling gait.
B.Diminishedvisualacuity.
C. Syncopewhenbending.
D. handstremors.
E. Urinaryincontinence
10. Thechargenurseobservesanewgraduate'sperformanceofwoundcare.
Which technique indicates that the employee is effectively cleansing the
wound?
A. Startsatthewoundsiteandmovesoutwardusingcircularmotions.
B. Cleansesfromtheouterareaofthewoundtowardthecenter
C. Usesasterileswabtogooverthewoundsitetwice.
D. Scrubswoundvigorouslyforatleasttwo minutes
11. Thenurseisevaluatingthefluidbalanceoftheclientwhowasadmitted
yesterday with dehydration and who has been receiving iv fluids since
admission.An increase in which parameter indicates to the nurse that the
client is rehydrating.
A. Serumhaematocrit.
B. Urinespecificgravity.
C. PulseRate.
D. Urinaryoutput.
, HESI RN FUNDAMENTALS EXAM | 3 VERSIONS COMBINED
LATEST 2023 GRADED A+
12. In-homehospicecareisarrangedforaclientwithstage4lung cancer. While
the palliative nurse is arranging for discharge, the client verbalizes
concerns about pain. What action should the nurse implement?
a. Explaintherespiratoryproblemsthatcanoccurwithmorphineuse.
b. Teachfamilyhowtoevaluatetheeffectivenessof analgesics.
c. Recommendaskingthehealthcareprofessionalforapatient-controlled
analgesic (PCA) pump.
d. Provideclientwithascheduleofaround-the-clockprescribedanalgesicuse.
13. Thenursebeginstosuctionaclient’soropharynxasseeninthepicture. What
action should the nurse take next?
a. Positionsuctioninthe trachea.
b. Applynasalcannulaoxygen.
c. Insertatongueblade.
d. Observethesuctionsecretion.
14. Whileinterviewingaclient,thenurserecordstheassessmentinthe
electronic health record. Which statement is most
accurateregarding electronic documentation during an interview?
a. Theinterviewprocessisenhancedwithelectronicdocumentationandallo
ws the client to speak at a normal pace.
b. Completingtheelectronicrecordduringaninterviewisalegaloblig
ation of the examining nurse.
c. Thenursehaslimitedabilitytoobservenon-verbalcommunicationwhile
entering the assessment electronically.
d. Theclient’scomfortlevelisincreasedwhenthenursebreakseye-contactto
type notes into the record.
15. Thenursemeasurestheclient’sbloodpressure(BP)andnotesthatitis
significantly higher than the previous reading. What should the nurse do
next? (Select all that apply).
a. Determinetheclient’sactivitiesandfeelingspriortotheBPmeasurement.
b. RetaketheClient'sbloodpressureintheoppositearm
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