Nursing Fundamentals Practice Questions, Exams of Advanced Education

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HESI FUNDAMENTALS EXAM

a 35 year old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home and die. What intervention should the nurse initiate? A. evaluate the client's mental status for competence to refuse treatment B. review the client's medical record for an advance directive C. determine if a DNR prescription has been obtained D. document that the client is being discharged against medical advice - A. evaluate the client's mental status for competence to refuse treatment A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicated the client's protein status for the longest length of time. A. Urine urea B. transferrin C. prealbumin D. serum albumin - D. serum albumin What client statement indicates to the nurse that the client requires assistance with bathing? A. "I only bathe every other day" B. "I left my eyeglasses at home" C. "I don't understand why I'm so weak and tired" D. "I wasn't able to pack a bag before I left for the hospital" - C. "I don't understand why I'm so weak and tired" How should a nurse handle linens that are soiled with incontinent feces? A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room

D. place an isolation hamper in the client's room and discard the linens in it - D. place an isolation hamper in the client's room and discard the linens in it When caring for an immobile client, what nursing diagnosis has the highest priority? A. altered tissue perfusion B. impaired gas exchange C. risk for fluid volume deficit D. risk for impaired skin integrity - B. impaired gas exchange The nurse assess an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the last hour. He has wet- sounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is the most important for the nurse to implement? A. encourage additional additional fluid intake B. provide the client with an additional blanket C. turn the patient Q D. administer a PRN anti hypertensive prescription - C. turn the patient Q The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's case? A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago B. the client tells the nurse that she does not have much of an appetite today C. the husband, who is the caregiver, begins to weep when you ask how he is doing D. the nurse notes that there are numerous scatter rubs throughout the house - D. the nurse notes that there are numerous scatter rubs throughout the house The nurse removes the dressing on a client's heel that is covering a pressure sore one-inch in diameter and finds that there is straw-colored drainage seeping from the wound. What description of this finding should the nurse include in the client's record? A. stage 1 pressure sore draining sero-anguineous drainage B. one-inch pressure sore draining serous fluid

C. pressure sore draining serous fluid D. pressure sore on heel with a small amount of purulent drainage - B. one-inch pressure sore draining serous fluid A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 800 B. 0800, 1200, 1600, 2000 C. every other day at 0800 D. 0800, 1200, 1600, 2000, 0000, 0400 - B. 0800, 1200, 1600, 2000 The nurse working in the emergency department is assessing four client's ability to tolerate pain. Which client is likely to tolerate a higher level of pain. A. A 23-year-old woman who sprained her knee while biking B. a 55-year-old woman who has had moderate low back pain for three months C. A 10-year-old who was burned by a camp fire earlier today D. A 70 year-old who has a postoperative infection from a surgery one week ago - B. a 55-year-old woman who has had moderate low back pain for three months A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, " will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? a. "It won't hurt because you're such a big boy" b. "It may hurt a little because of the incision made in your throat" c. "It won't hurt because we put you to sleep" d. "It may hurt but we'll give you medicine to help you feel better" - d. "It may hurt but we'll give you medicine to help you feel better" A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been non compliant with the diet, based on which report from the 24-hour dietary recall? (select all that apply) A. bedtime snack of crackers and milk

B. breakfast of eggs, bacon, toast, and coffee C. lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee D. dinner of vegetable lasagna, tossed salad, sherbet, and iced tea E. snack of potato chips, and diet soda - A, B, C & E What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to a chronic venous insufficiency? A. check capillary refill of toes on lower extremity with Unna's paste boot B. apply dressing to a wound area before applying the Unna's paste boot C. remove the Unna's paste boot Q8H to assess wound healing D. wrap the leg from the knee down towards to foot - A. check capillary refill of toes on lower extremity with Unna's paste boot A male client has a nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for the client. A. Reassurance the client that his faith will be regained with time and support B. consult with the staff chaplain and ask that the chaplain visit with the client C. use reflective listening techniques when the client expresses spiritual doubts D. use distraction techniques during times of spiritual stress and crisis - C. use reflective listening techniques when the client expresses spiritual doubts A client has a nursing diagnosis of "Spiritual distress related to loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. instruct the client's family to focus on positive aspect of the client's life B. assist and support the client in establishing short-term goals C. encourage the client to make future plans, even if they are unrealistic D. help the client to accept the final stage of life - B. assist and support the client in establishing short- term goals A female nurse who sometimes tries to save time by putting medications in her uniform to clients, confides that after arriving home she found hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern?

a. accused of unprofessional conduct b. accused of diversion c. reported for stealing d. reported for a HIPAA violation - b. accused of diversion A signed consent form indicated a client should have an EKG, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plantiff because these events represent which infraction? A. An unintentional tort because the client benefited from having the myelogram B. Assault and battery with deliberate intent to deviate from the consent form C. A quisi-intentional because a similar mistake can happen to anyone D. failure to respect client autonomy to choose based on international tort law - B. Assault and battery with deliberate intent to deviate from the consent form A 75 year old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, starting the death is inevitable, but the client is discontinues and will not sign a DNR directive. A. review the client's most recent laboratory reports B. determine who is legally empowered to make decisions C. refer the client and family members for hospice D. notify the patient ethics committee of the client situation - B. determine who is legally empowered to make decisions The change nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? A. review the steps in the procedural manual B. refuse to perform the task that is beyond the nurse's experience C. ask another nurse to assist while implementing the procedure D. follow the agency's policy and procedure - B. refuse to perform the task that is beyond the nurse's experience

Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the health care provider. After consultation with the health care provider, the dose of the medication is changed and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse implement in response to this situation? A. Document the events that occurred in the nurse's notes B. notify the charge nurse that a medication error occurred C. submit a medication valence report to the supervisor D. discard the original medication administration record - A. Document the events that occurred in the nurse's notes On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? A. provide warm prune juice before the client goes to bed at night B. teach the client to splint the incision while walking to the bathroom C. remind the client to turn every two hours while lying in bed D. administer an analgesic before the client attempts to defecate - A. provide warm prune juice before the client goes to bed at night The home health nurse visits an elderly client who lives at home with her husband. The client is experiencing frequent episodes of diarrhea and bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? A. fluid volume imbalance B. impaired skin integrity C. caregiver role strain D. disturbed sleep pattern - A. fluid volume imbalance A nurse observes a student nurse taking a copy of a client's medication administration record. When questioned, the student states, "Another student is scheduled to administer medications for this client tomorrow, so I am going to make a copy to help my friend prepare for tomorrow's clinical". What response should the nurse provide first? A. Ask the nursing supervisor to meet with the students

B. Ask the client if permission was obtained from the client C. explain the records are hospital property and may not be removed D. notify the student's clinical instructor of the situation - C. explain the records are hospital property and may not be removed After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? A. read the consent form to the client before witnessing the client's signature B. determine if the client's spouse is willing to sign the consent form C. notify the surgeon that the consent form has not been signed D. administer an opioid antagonist prior to obtaining the client's signature - C. notify the surgeon that the consent form has not been signed A client who has been on bedrest for several days now has a prescription to progress activity as tolerated. When the nurse assists the client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? A. Instruct the patient to remain on bedrest until the healthcare provider is contracted B. encourage the client to take several slow, deep breaths while ambulating C. advise the client to sit on the side of the bed for a few minutes before standing again D. help the client to remain standing by the bedside until the dizziness is relieved - C. advise the client to sit on the side of the bed for a few minutes before standing again The charge nurse observes an unlicensed assistive personnel (UAP) bending at the waist to lift a 20- pound box of medical supplies off the treatment room floor. What instruction should the charge nurse provide to the UAP? A. ask another staff member for assistance B. request that supplies are delivered in smaller containers C. push the box against the wall to provide support while lifting D. bend at the knees when lifting heavy objects - D. bend at the knees when lifting heavy objects An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?

A. apply flannel pajamas to provide warmth B. administer a PRN dose of ibuprofen C. Drape the sheets over the foot board of the bed D. perform ROM exercises in a warm tub - C. Drape the sheets over the foot board of the bed A client is admitted to the hospital with intractable pain. When instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. a client's pain will be difficult to manage, since the cause is still unknown B. take measures to promote as much comfort as possible C. report any signs of drug addiction to the nurse immediately D. wait until the client's pain is gone before assisting with personal care - B. take measures to promote as much comfort as possible A male client arrives at the out patient surgery center for a scheduled needle aspiration of the knee. He tells the nurse that he has already given verbal consent for the procedure to the health care provider. What action should the nurse implement? A. verify the client's consent with the health care provider B. document that the client has given consent for the needle aspiration C. witness the client's signature on the consent form D. notify the healthcare provider that the client is ready for the procedure - C. witness the client's signature on the consent form In assessing a client's femoral pulse, the nurse must use deep pulsation to feel the pulsation while the client is in a supine position. What action should the nurse implement? A. document the presence and volume of the pulse palpated B. elevate the head of the bed and attempt to palpate the site again C. record the presence of pitting edema in the inguinal area D. use a thigh cuff to measure the blood pressure in the leg - A. document the presence and volume of the pulse palpated A nurse is preparing to insert a rectal suppository and observes a small amount of rectal bleeding. What action should the nurse implement?

A. insert the suppository very gently being careful not to further injure the rectal bleeding. What action should the nurse implement? A. insert the suppository very gently being careful not to further the rectal mucosa B. withhold the administration of the suppository until contacting the healthcare provider C. administer the medication as scheduled after assessing the client's vital signs D. Ask the pharmacist to send an alternate from the prescribed medication to the unit - B. withhold the administration of the suppository until contacting the healthcare provider The nurse is preparing to irrigate a client's indwelling catheter using an open technique. What action should the nurse take after applying gloves? A. Draw up the irrigating solution into the syringe B. use aseptic technique to instill the irrigating solution C. empty the client's urinary catheter D. secure the client's catheter to the drainage tubing - A. Draw up the irrigating solution into the syringe When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse? A. there are no dependent loops in the drainage tubing B. the clamp on the urinary drainage bag is open C. the drainage tubing is secured over the siderail D. the urinary drainage bag is attached to the bed frame - B. the clamp on the urinary drainage bag is open While preparing to insert a rectal suppository in a male adult client, the nurse observes that the client is holding his breath while bearing down. What action should the nurse implement? A. gently insert the lubricated suppository four inches into the rectum B. instruct the client to take slow deep breaths and stop bearing down C. advise the client to continue to bear down without holding his breath D. perform a digital exam to determine a fecal impaction is present - B. instruct the client to take slow deep breaths and stop bearing down

The nurse is completing the plan of care for a client who is admitted for benign prostatic hypertrophy. Which data should the nurse document as a subjective findings? A. complains of inability to empty bladder B. temperature of 99.80F and pulse of 108 C. post-voided residual volume of 750ml D. specimen collection for culture and sensitivity - A. complains of inability to empty bladder While the nurse is administering a bolus feeding to a client via NG tube, the client begins to vomit. What action should the nurse implement first? A. discontinue the administration of the bolus feeding B. administer a PRN dose of a prescribed antiemetic C. auscultate the client's breath sounds bilaterally D. elevate the head of the bed to a high fowler's position - A. discontinue the administration of the bolus feeding What is the rationale for using the nursing process in planning care for clients? A. to establish nursing theory that incorporates the biopsychosocial nature of humans B. as a scientific process to identify nursing diagnoses of a client's healthcare problems C. to promote the managment of client care in collaboration with other health care professionals D. as a tool to organize thinking and clinical decision making about clients' healthcare needs - D. as a tool to organize thinking and clinical decision making about clients' healthcare needs What activity should the nurse use in the evaluation phase of the nurse process? A. ask a client to evaluate the nursing care provided B. examine the effectiveness of nursing interventions toward meeting client outcomes C. determine whether a client's health problems have been alleviated D. document the nursing care plan in the progress notes - B. examine the effectiveness of nursing interventions toward meeting client outcomes Which statement is an example of a correctly written nursing diagnosis statement?

A. ineffective coping related to response to positive biopsy B. risk for impaired tissue integrity C. altered tissue perfusion related to congestive heart failure D. altered urinary elimination related to urinary tract infection - A. ineffective coping related to response to positive biopsy What action by the nurse demonstrated culturally sensitive care? A. explains the differences between western medical care and cultural folk remedies B. applies knowledge of a cultural group unless a client embraces western customs C. avoids questions about male-female relationship D. asks permission before touching a client - D. asks permission before touching a client A nurse is becoming increasingly frustrated by the family members' efforts to participate in the care of a hospitalized client. What action should the nurse implement to cope with these feelings of frustration? A. allow the situation to continue until a family member's action may harm the client B. explain to the family that multiple visitors are exhausting to the client C. explain one's own culturally based values, beliefs, attitudes and practices D. suggest that other cultural practices be substituted by the family members - C. explain one's own culturally based values, beliefs, attitudes and practices Which technique is most important for the nurse to implement when performing a physical assessment? A. the medical systems model B. an approach related to a nursing model C. a consistent, systemic approach D. a head-to-toe approach - C. a consistent, systemic approach a 73 year old Hispanic client is seen at the community health clinic with a history of protein malnutrition. What information should the nurse obtain first? A. foods and liquids consumed during the past 24 hours B. amount of liquid protein supplements consumed daily

C. grains and legume combinations used by the client D. usual weekly intake of milk products and red meats - A. foods and liquids consumed during the past 24 hours The nurse formulates the nursing diagnosis of "ineffective health maintenance related to lack of motivation" for a client with type 2 diabetes. Which finding supports this nursing diagnosis? A. does not check capillary blood glucose as directed B. cannot identify signs or symptoms of high and low blood glucose C. occasionally forgets to take daily prescribed medication D. eats anything and does not think diet makes a difference in health - D. eats anything and does not think diet makes a difference in health Which statement correctly identifies a written learning objective for a client with peripheral vascular disease? A. the nurse will provide client instruction for daily foot care B. upon discharge, the client will list three ways to protect the feet from injury C. after instruction, the nurse will ensure the client understands foot care rationale D. the client will demonstrate proper trimming toenail technique - B. upon discharge, the client will list three ways to protect the feet from injury A middle-aged woman who enjoys being a teacher a mentor feels that she should pass down her legacy of knowledge and skills to the younger generation. According to Erikson, she is involved in what developmental stage? A. valuing wisdom B. generativity C. ego integrity D. identification - B. generativity which statement best describes durable power of attorney for health care? A. the healthcare decisions made my another person designated by the client are not legally binding B. instructions about actions to be taken in the event of a client's terminal or irreversible condition are not legally binding

C. the client signs a document that designated another person to make legally binding healthcare decisions if client is unable to do so D. directions regarding care in the event of a terminal or irreversible condition must be documented to ensure that they are legally binding - C. the client signs a document that designated another person to make legally binding healthcare decisions if client is unable to do so A male client with an infected wound tells the nurse that he follows a macrobiotic diet. Which type of foods should the nurse recommend that the client select from the hospital menu? A. increased amount of vitamin c and beta carotene rich foods B. limited complex carbohydrates and fiber C. low fat and low sodium foods D. combination of plant proteins to provide essential amino acids - D. combination of plant proteins to provide essential amino acids A client with raynaud's disease asks the nurse about using biofeedback for self- management of symptoms. What response is best for the nurse to provide? A. although biofeedback is easily learned, it is mostly often used to manage exacerbation of symptoms B. biofeedback allows the client to control voluntary responses to promote peripheral vasodilation C. the responses to biofeedback have not been well established and may be a waste of time and money D. biofeedback requires extensive training to retain voluntary muscles, not involuntary - B. biofeedback allows the client to control voluntary responses to promote peripheral vasodilation A female client informs the nurse that she uses herbal therapies to supplement her diet and manage common ailments. What information should the nurse offer the client about general use of herbal supplements? A. herbal therapies may mask the symptoms of serious disease, so frequent medical evaluation is requiring during use B. herbs should be obtained from manufacturers with a history of quality control of their supplements C. there is no evidence that herbs are safe or effective as compared to conventional supplements in maintaining health D. most herbs are toxic of carcinogenic and should be used only when proven effective - B. herbs should be obtained from manufacturers with a history of quality control of their supplements