Additional HESI Fundamentals
Recommended Sets
B- ✅✅ -Two hours before a client's scheduled surgery, the nurse is completing the
preoperative checklist. Which information requires the most immediate action by the nurse?
A. Surgical consent form is not signed
B. Preoperative serum potassium level is 2.8 mEq/L (2.8mmol/L)
C.Preoperative chest x-ray report is not available
D. Client's pulse oximeter reading is 96%
C- ✅✅ -One hour after major abdominal surgery, a client in the post anesthesia care unit
(PACU) has a blood pressure (BP) of 136/80 mmHg. Fifteen minutes later it is 114/72 mmHg.
Which action should the nurse take first?
A. Increase frequency of BP assessments
B. Review the client's baseline BP trends
C. Check the abdominal surgical dressing
D. Encourage the client to breathe deeply
B- ✅✅ -The nurse is assessing a client's arteriovenous (AV) fistula. Which finding provides
evidence of its normal function?
A. Ecchymotic area
B. Enlarged vein
C. Pulselessness
D. Redness
C- ✅✅ -Which instruction should the nurse include in the discharge teaching for a client who
has gastroesophageal reflux?
A. Encourage the client to lie down and rest after meals
B. Remind the client to avoid high-fiber foods
C. Teach the client to elevate the head of the bed on blocks
D. Instruct the client to use antacids only as a last resort
B- ✅✅ -Following a transurethral resection of the prostate (TURP), a client is discharged from
the hospital with an indwelling urinary catheter. Which instruction is important for the nurse to
include in the discharge teaching plan?
A. Avoid driving a car for 2 weeks
B. Drink 3 liters of water each day
C. Eliminate all spicy foods from your diet
D. Clamp the catheter when taking a shower
A- ✅✅ -A client with chronic cirrhosis has esophageal varies. It is most important for the nurse
to monitor the client for the onset of which problem?
A. Brown, foamy urine
,B. Anorexia
C. Clay-colored stool
D. Hematemesis
B- ✅✅ -After three days of persistent epigastric pain, a female client presents to the clinic.
She has been taking oral antacids without relief. Her vital signs are heart rate 122 beats/min,
respirations 16 breaths/minute, oxygen saturation 96%, and blood pressure 116/70mmHg. The
nurse obtains a 12-lead electrocardiogram (ECG). Which assessment finding is most critical?
A. Irregular pulse rate
B. ST elevation in three leads
C. Complaint of radiating jaw pain
D. Bile colored emesis
A- ✅✅ -A client's laboratory findings indicate elevations in thyroxine and triiodothyronine
hormones. The nurse suspects that the client may have hyperthyroidism. Which assessment
finding is most often associated with hyperthyroidism?
A. Increased pulse rate
B. Diarrhea stools
C. Atrophied thyroid gland
D. Periorbital edema
D- ✅✅ -A young adult male client has a diagnosis of epididymitis and a positive culture for
Escherichia coli. Which information should the nurse include in the teaching plan?
A. Avoid penile contact with the rectal area
B. Epididymitis is a pre-cancerous condition
C. Obtain an annual prostate digital exam
D. Surgical intervention is often indicated
C- ✅✅ -The drainage in the chest tube of a client with emphysema has changed from viscous
green to clear watery fluid. Which action is best for the nurse to take?
A. Obtain a specimen of the drainage for culture
B. "Milk" the tube to remove any clots
C. Maintain the current IV antibiotic schedule
D. Schedule a portable chest x-ray per PRN protocol
B- ✅✅ -While planning care for a client with carpal tunnel syndrome, the nurse identifies a
collaborative problem of pain. What is the etiology of this problem?
A. Diminished blood flow
B. Compression of a nerve
C. Irritation of nerve endings
D. Ischemic tissue changes
,D- ✅✅ -A client is being treated for acute kidney injury. On examination, the client has a
weight gain of 4.4 lbs (2kg) in 24 hours and exhibits changes in mental status. Which
intervention should the nurse implement?
A. Monitor daily sodium intake
B. Assess for dependent pitting edema
C. Record usual eating patterns
D. Obtain serum creatine levels daily
A- ✅✅ -A female client who works as a data entry clerk is concerned as to how her recent
diagnosis of Raynaud's syndrome is going to affect her job performance. Which instruction
should the nurse provide this client?
A. Use a space heater to keep the workplace warm
B. Obtain a keyboard designed to limit wrist flexion
C. Keep both hands elevated during work breaks
D. Take a multivitamin that contains vitamin D daily
B- ✅✅ -A client has an absolute neutrophil count (ANC) of 500/mm^3 after completing
chemotherapy. Which intervention is most important for the nurse to implement?
A. Implement bleeding precautions
B. Place the client in protective isolation
C. Assess vital signs every 4 hours
D. Review need for pneumococcal vaccine
A- ✅✅ -A client is receiving chemotherapy for treatment of metastatic carcinoma. When
monitoring the client for systemic side effects, which assessment finding warrants intervention
by the nurse?
A. Leukopenia
B. Polycythemia
C. Ascites
D. Nystagmus
C- ✅✅ -A client is diagnosed with diverticulosis following a colonoscopy. The client denies any
symptoms, and asks the nurse what to expect. Which is the best response by the nurse?
A. Episodes of burning pain are commonly experienced
B. Appetite loss, with resultant feelings of weakness, are common problems
C. Symptoms may not occur unless sacs become inflamed
D. As the sacs enlarge pain may be experienced in the lower abdomen
D- ✅✅ -A client is admitted with a deep and productive cough, hemoptysis, and a low-grade
fever. The client's Mantoux skin test has a 15mm induration. Which intervention should the
nurse implement first?
A. Administer the initial dose of rifampin and isoniazid
B. Collect a sputum specimen for acid-fast bacillus
C. Provide a mask for the client to wear in public areas
, D. Initiate airborne particulate isolation precautions
A- ✅✅ -A client with Cushing's syndrome is recovering from an elective laparoscopic
procedure. Which assessment finding warrants immediate intervention by the nurse?
A. Irregular apical pulse
B. Pitting ankle edema
C. Quarter size blood spot on dressing
D. Purple marks on skin of the abdomen
A- ✅✅ -A female client who recently married returns to the clinic with recurrent cystitis and
urethritis. The client presents with pain on urinating, urinary frequency, and urgency. Which
additional information should the nurse obtain?
A. Review a recent urinalysis for calcium oxalate
B. Examine a client's history for any genetic renal disease
C. Ask if she has recently has a streptococcus infection
D. Inquire about hygiene practices after sexual intercourse
B- ✅✅ -The nurse provides dietary instructions about iron rich foods to a client with iron
deficiency anemia. Which food selection made by the client indicates a need for additional
instructions?
A. Liver
B. Oranges
C. Leafy green vegetables
D. Kidney beans
A- ✅✅ -A client with hyperparathyroidism reports a sudden onset of severe flank pain. Which
intervention should the nurse include in the client's plan of care?
A. Begin straining all urine
B. Implement seizure precautions
C. Administer a PRN dose of a laxative
D. Initiate cardiac telemetry
D- ✅✅ -The nurse is caring for a client on a rehabilitation unit who has right cerebrovascular
accident and is struggling with independent self-care. The nurse places a large mirror in the
client's room. Which instruction should the nurse provide the client?
A. Mirrors reflect light to brighten the room so you can see better
B. A hoe-like environment helps you relax and feel more confident
C. Check your appearance before leaving the room
D. Use the mirror to watch yourself while dressing
A, D, E -✅✅ -An older client who us agitated, dyspneic, orthopneic, and using accessory
muscles to breathe is admitted for further treatment. Initial assessment includes a heart rate 128
beats/minute and irregular respirations 38 breaths/minute, blood pressure 168/100 mmHg,
wheezes and crackles in all lung fields. An hour after the administration of furosemide 60 mg IV,
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