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Fund HESI
Fund practice HESI
| Question | Answer | Rational |
|---|---|---|
| During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? A. Listen and show interest as the client expresses these feelings. B. Reinforce that this behavior means they were not true friends. C. Ask the healthcare provider for a psychiatric consult. D. Continue with the assessment and tell the client not to worry. | A. Listen and show interest as the client expresses these feelings. | When a client begins to cry and express feelings, a therapeutic nursing intervention is to listen and show interest as the client expresses feelings (A). (B) is not a therapeutic option and the nurse does not know the dynamics of their relationships. (C) is not indicated at this time. (D) is non-therapeutic and offers false hope. |
| The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? A. Observe the appearance of the skin under the ice pack. B. Instruct the client regarding the need for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client how long the ice was applied to the skin. | A. Observe the appearance of the skin under the ice pack. | The client has been using an ice pack without the protective covering. The first action the nurse should take is to assess the skin for any possible thermal injury. If no injury to the skin has occurred, the nurse can then explain the need for a cover and reapply the ice pack with the cover in place. |
| The n observes an (UAP) checking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. Which action is most important for the nurse to implement? A. Tell the UAP to use a larger cuff at the next scheduled assessment. B. Reassess the client's blood pressure using a larger cuff. C. Have the unit educator review this procedure with the UAPs. D. Teach the UAP the correct technique for assessing blood pressure. | B. Reassess the client's blood pressure using a larger cuff. | An unlicensed assistive personnel (UAP) is using the wrong sized cuff to check a blood pressure. The most important action is to ensure that an accurate blood pressure reading is obtained. The nurse should reassess the blood pressure with the correct size cuff. Reassessment should not be postponed. |
| At the time of the first dressing change, the client refuses to look at her mastectomy incision. The N tells the pt that the incision is healing well, but the pt refuses to talk about it. Which is the best response to this pt silence? A. "Looking at your incision can be frightening, but facing this fear is a necessary part of your recovery." B. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." | B. "It is OK if you don't want to talk about your surgery. I will be available when you are ready." | When a client is reluctant to look at a surgical wound or refuses to talk about the surgery, the nurse should reflect that these feelings are OK and that the nurse is available when the client is ready. Such a response displays sensitivity and understanding without judging the client. On the other hand, telling a client how she should feel is judgmental and insensitive. |
| A male client with a hx of hypertension tells the nurse that he is tired of taking antihypertensive meds and is going to try spiritual meditation instead. What should be the N's first response? A. "It is important that you continue your meds while learning to meditate." B. "Spiritual meditation requires a time commitment of 15 to 20 minutes daily." C. "Obtain your healthcare provider's permission before starting meditation." D. "Complementary therapy and western medicine can be effective for you." | A. "It is important that you continue your meds while learning to meditate." | The prolonged practice of meditation may lead to a reduced need for antihypertensive medications. However, the medications must be continued while the physiologic response to meditation is monitored. The healthcare provider should be informed, but permission is not required to meditate. |
| During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? A. Place the stethoscope bell at random points on the posterior chest. B. Use the stethoscope bell over the valvular areas of the anterior chest. C. Move the diaphragm of the stethoscope over the left anterior chest. D. Position the diaphragm of the stethoscope at Erb's point on the chest. | B. Use the stethoscope bell over the valvular areas of the anterior chest. | Abnormal heart sounds are best heard with the bell of the stethoscope, which picks up lower-pitched sounds, that is placed at points on the anterior chest. |
| A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? A. Demonstrates loss of remote memory. B. Exhibits expressive dysphasia. C. Has a diminished attention span. D. Is disoriented to place and time. | D. Is disoriented to place and time. | The client is exhibiting disorientation. Loss of remote memory refers to memory of the distant past. The client is able to express himself without difficulty, and does not demonstrate a diminished attention span. |
| A client with multiple sclerosis is prescribed Dantrolene (Dantrium) 0.1 grams PO bid for spasticity. Dantrolene is available in 100 mg capsules. How many capsules should the nurse administer? (Enter numeric value only.) | 1 | Using the conversion of 1 gram = 1000 mg: 0.1 gram = 100 mg 100 mg = 1 capsule |
| The (UAP) working on a chronic neuro unit asks the N to help determine the safest way to transfer an older client with left-sided weakness from the bed to the chair. Which method describes the correct transfer procedure for this client? A. Have the client place the left foot next to the chair and pivot to the left before sitting. B. Move the chair parallel to the right side of the bed, and stand the client on the right foot. | B. Move the chair parallel to the right side of the bed, and stand the client on the right foot. | When positioning a client for transfer from bed to chair when the client has left-sided weakness, use the client's stronger side, the right side, for weight-bearing during the transfer. In this case, the client should stand on the right foot during the transfer. |
| A client who is 5 foot 5 inches tall and weighs 200 pounds is scheduled for surgery the next day. Which question is most important for the nurse to include during the preoperative assessment? A. "What is your daily calorie consumption?" B. "What vitamin and mineral supplements do you take?" C. "Do you feel that you are overweight?" D. "Will a clear liquid diet be okay after surgery?" | B. "What vitamin and mineral supplements do you take?" | In the preoperative assessment, the nurse should assess the client's use of vitamin and mineral supplements. These products may impact medications used during the operative period. The nature of the surgery and anesthesia will determine the need for a clear liquid diet, rather than the client's preference. Addressing long-term diet therapy is best done after surgery and recovery. |
| A postoperative client will need to perform daily dressing changes after discharge. Which outcome response best demonstrates the client's readiness to manage wound care after discharge? A. Asking relevant questions regarding the dressing change. B. Stating theability to complete the wound care regimen. C. Demonstrating the wound care procedure correctly. D. Showing all the necessary supplies for wound care. | C. Demonstrating the wound care procedure correctly. | A return demonstration of a procedure provides an objective assessment of a client's ability to perform a task, while client statements or questions are subjective measures.Showing that the client possesses the necessary supplies is important, but it is less of a priority prior to discharge than the nurse's assessment of the client's ability to complete the wound care. |
| The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? A. Encourage the client to cough to help loosen secretions. B. Advise the client to increase the intake of oral fluids. C. Rotate the suction catheter to obtain any remaining secretions. D. Re-oxygenate the client before attempting to suction again. | D. Re-oxygenate the client before attempting to suction again. | Nasotracheal suctioning should not be continued for longer than ten to fifteen seconds, since the client's oxygenation is compromised during this time. Additional suctioning may continue after the client has received oxygen. |
| A resident in a skilled nursing facility for short-term rehab after a hip replacement tells the N, "I don't want more blood taken for those useless tests." Which narrative should the N enter in the ct's MR? A. Provider notified of failure to collect specimens for prescribed blood studies. B. Blood specimens not collected b/c ct no longer wants blood tests performed. C. Healthcare provider notified of client's refusal to have blood specimens collected for testing. | C. Healthcare provider notified of client's refusal to have blood specimens collected for testing. | When a client refuses a treatment, the exact words of the client regarding the client's refusal of care should be documented in a narrative format. The nurse should not editorialize, make judgments, or document assumptions about the client's wishes. |
| A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs? A. Autopsy of the body is prohibited. B. Blood transfusions are forbidden. C. Alcohol use in any form is not allowed. D. A vegetarian diet must be followed. | B. Blood transfusions are forbidden. | Blood transfusions are forbidden in the Jehovah's Witness religion. Judaism prohibits autopsies and Buddhism forbids the use of alcohol and drugs. Many of these sects follow a vegetarian diet, but the direct impact on nursing care concerns beliefs about transfusions. |
| The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? A. Inherited familial health disorders. B. Chronic health problems. C. Reason for seeking health care. D. Undetected disorders. | A. Inherited familial health disorders. | A genogram that is used during the health assessment process identifies genetic and familial health disorders. It may not identify the client's chronic health problems. A genogram is not a diagnostic tool to detect disorders, such as those based on pathological findings or DNA. |
| Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? A. Chocolate pudding. B. Graham crackers. C. Sugar free gelatin. D. Apple slices. | A. Chocolate pudding. | The client with myasthenia gravis is at high risk for altered nutrition because of fatigue and muscle weakness resulting in dysphagia. Snacks that are semisolid, such as pudding are easy to swallow, require minimal chewing effort, and provide calories and protein.Gelatin does not provide any nutritional value and the other options require energy to chew and are more difficult to swallow than pudding. |
| A ct's spouse is learning passive ROM for the ct's contracted shoulder. The N observes that the spouse is holding the ct's arm above and below the elbow. Which nursing action should the N implement? A. Acknowledge that the spouse is supporting the arm correctly. B. Encourage the spouse to keep the joint covered to maintain warmth. C. Reinforce the need to grip directly under the joint for better support. D. Instruct the spouse to grip directly over the joint for better motion. | A. Acknowledge that the spouse is supporting the arm correctly. | The client's spouse is correctly holding the arm above and below the elbow to perform passive rangeof motion to the contracted shoulder. The nurse should acknowledge this fact. The joint that is being exercised should be uncovered while the rest of the body should remain covered for warmth and privacy. |
| What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? A. It is more difficult to find a superficial vein in the feet and ankles. B. A decreased flow rate could result in the formation of a thrombosis. C. A cannulated extremity is more difficult to move when the leg or foot is used. D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. | B. A decreased flow rate could result in the formation of a thrombosis. | Venous return is usually better in the up extremities. Cannulation of the veins in the low extremities the risk of thrombus formation which, if dislodged, could be life-threatening. Superficial veins are often very easy to find in the feet and legs. Handling a leg or foot with an IV is not any more difficult than handling an arm or hand. Even if the N believes moving a cannulated leg is more difficult, this is not the most important reason for using the upper extremities. Pain is not a consideration. |
| Which response by a client with a nursing diagnosis of "Spiritual distress," indicates to the nurse that a desired outcome measure has been met? A. Expresses concern about the meaning and importance of life. B. Remains angry at God for the continuation of the illness. C. Accepts that punishment from God is not related to illness. D. Refuses to participate in religious rituals that have no meaning. | C. Accepts that punishment from God is not related to illness. | Acceptance that her illness is not God punishing her, indicates a desired outcome for some degree of resolution of spiritual distress. |
| A male ct with obesity talk w/ the N his plans to begin a long-term wt loss regimen. Plus to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a wk & take stress mgnt classes. After praising the ct for decision, which instruction is most important for the nurse to provide? A. "Be sure to have a complete physical exam b4 beginning your planned exercise program." B. "Make sure to monitor your weight loss regularly to provide a sense of accomplishment and motivation." | A. "Be sure to have a complete physical exam b4 beginning your planned exercise program." | A client with obesity who intends to begin a weight loss and exercise program may be at risk for cardiovascular complications. The most important teaching is to encourage the client to have a complete medical evaluation so that the client will not begin a dangerous level of exercise when he is not sufficiently fit. Vigorous exercise may result in chest pain, a heart attack, or stroke. |
| A client with acute hemorrhagic anemia is to receive four units of packed (RBCs) as rapidly as possible. Which intervention is most important for the nurse to implement? A. Obtain the pre-transfusion hemoglobin level. B. Prime the tubing and prepare a blood pump set-up. C. Monitor vital signs every 15 minutes for the first hour. D. Ensure the accuracy of the blood type match. | D. Ensure the accuracy of the blood type match. | Any time blood is administered, the nurse should ensure the accuracy of the blood type match in order to prevent a possible hemolytic reaction. Preparing the tubing, checking the baseline hemoglobin, and monitoring vital signs should also be implemented prior to administering blood, but checking the blood type has the highest priority. |
| A male ct being discharged w/ a rx for the bronchodilator theophylline tells the N that he understands he is to take 3 doses the med each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the N advise the ct to follow? A. 9 a.m., 1 p.m., and 5 p.m. B. 8 a.m., 4 p.m., and midnight. C. Before breakfast, before lunch, and before dinner. D. With breakfast, with lunch, and with dinner. | B. 8 a.m., 4 p.m., and midnight. | Theophylline should be administered on a regular, around-the-clock schedule to provide the best bronchodilating effect and to reduce the potential for adverse effects. Food may alter absorption of the medication, so it should not be taken with meals. |
| The nurse notices that the mother of a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? A. Talk directly to the child instead of the mother. B. Continue asking the mother questions about the child. C. Ask another nurse to interview the mother now. D. Tell the mother politely to look at you when answering. | B. Continue asking the mother questions about the child. | Eye contact is a culturally-influenced form of non-verbal communication. In some non-Western cultures, such as the Vietnamese culture, a client or family member may avoid eye contact as a form of respect, so the nurse should continue to ask the mother questions about the child. |
| On admission, a ct presents a signed living will that includes a (DNR) rx. When the ct stops breathing, the nurse performs (CPR) & successfully revives the ct. What legal issues could be brought against the N? A. Assault. B. Battery. C. Malpractice. D. False imprisonment. | B. Battery. | Civil laws protect individual rights and include intentional torts, such as assault (an intentional threat to engage in harmful contact with another) or battery (unwanted touching).Performing any procedure against the client’s wishes can potentially create a legal issue, such as battery, even if the procedure is of questionable benefit to the client. |
| A client is receiving alprazolam (Xanax) 0.75 mg PO bid for anxiety. Alprazolam is available in 0.5 mg scored tablets. How many tablets should the nurse administer? (Enter numeric value only.) | 1.5 | Using the formula, Desired / Available x 1 tablet = 0.75 mg / 0.5 mg x 1 = 1.5 tablets |
| The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? A. Immediately after exhalation. B. During the inhalation. C. At the end of three inhalations. D. Immediately after inhalation. | B. During the inhalation. | The client should be instructed to deliver medication through a metered inhaler during the last part of inhalation. After the medication is delivered, the client should remove the mouthpiece, keeping his/her lips closed and hold the breath for several seconds to allow for distribution of the medication. |
| A female client with a NG tube attached to low suction states that she is nauseated. The N assesses that there has been no drainage through the NG tube in the last 2 hrs. Which action should the N make first? A. Irrigate the nasogastric tube with sterile normal saline. B. Reposition the client on her side. C. Advance the nasogastric tube an additional five centimeters. D. Administer an intravenous antiemetic prescribed for PRN use. | B. Reposition the client on her side. | The nurse has identified two things suggesting the the nasogastric tube is not functioning properly; the client is nauseated and no drainage from the tube in 2 hours. The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea. The least invasive intervention should be attempted first. This includes repositioning the client to her side. The tube may need to be irrigated or advanced but these actions should follow repositioning the client. |
| 3 days after surgery, a male ct observes his colostomy for the first time. He becomes quite upset and tells the N that it is much bigger than he expected. What is the best response by the nurse? A. Reassure the ct that he will become accustomed to the stoma appearance in time. B. Instruct the ct that the stoma will become smaller when the initial swelling diminishes. C. Offer to contact a member of the local ostomy support group to help him with his concerns. | B. Instruct the ct that the stoma will become smaller when the initial swelling diminishes. | Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the swelling is diminished. This will help reduce the client's anxiety and promote acceptance of the colostomy. |
| When conducting a admission assessment, the N should ask the ct about the use of complementary healing practices. Which statement is accurate regarding the use of these practices? A. Complementary healing practices interfere w/ the efficacy of the medical model of treatment. B. Conventional meds are likely to interact w/ folk remedies & cause adverse effects. C. Many complementary healing practices can be used in conjunction w/ conventional practices. | C. Many complementary healing practices can be used in conjunction w/ conventional practices. | Conventional approaches to health care can be depersonalizing and often fail to take into consideration all aspects of an individual, including body, mind, and spirit. Often complementary healing practices can be used in conjunction with conventional medical practices, rather than interfering with conventional practices, causing adverse effects, or replacing conventional medical care. |
| An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? A. Generalized dry skin. B. Localized dry skin on lower extremities. C. Red flush over entire skin surface. D. Rashes in the axillary, groin, and skin fold regions. | D. Rashes in the axillary, groin, and skin fold regions. | Immobility, constant contact with bed clothing, and excessive heat and moisture in areas where air flow is limited contributes to bacterial and fungal growth, which increases the risk for rashes (D), skin breakdown, and the development of pressure ulcers. (A, B, and C) do not address the concepts of inflammation and tissue integrity. |
| The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? A. A college-age track runner with a sprained ankle. B. A lactating woman nursing her 3-day-old infant. C. A school-aged child with Type 2 diabetes. D. An elderly man being treated for a peptic ulcer. | B. A lactating woman nursing her 3-day-old infant. | A lactating woman has the greatest need for additional protein intake. Orthopedic injuries, typoe 2 diabetes, and peptic ulcers are all conditions that require protein, but do not have the increased metabolic protein demands of lactation. |
| A client with type 2 diabetes is receiving metformin (Glucophage) 1 gram PO twice daily. The medication is available in 500 mg tablets. How many tablets should the nurse administer? (Enter numeric value only.) | 2 | Using the known equivalent, 1 gram = 1000 mg, the nurse should first convert the dose to the same unit of measurement, which is 1 gram = 1000 mg. Using the formula, Desired / Available x 1 tablets: 1000 mg / 500 mg x 1 = 2 tablets |
| A Sub-Saharan African widowed immigrant woman lives w her dead husband's brother and his fam, which includes the BILs children & widow's adult children. Each fam member speaks English. Sx is recommended for this ct. What is the best plan to obtain consent for sx for this ct? B. Encourage the ct to make her own decision regarding surgery. C. Tell the surgeon that BIL will decide after explanation of the proposed sx is provided to him and the widow. | C. Tell the surgeon that BIL will decide after explanation of the proposed sx is provided to him and the widow. | Customary law in some rural sub-Saharan countries encompasses wife inheritance and polygamy; the widow becomes the inherited wife of the her BIL. In those rural areas women live in a patriarchal fam where decisions are made by men. Most likely, the BIL will make the decision for his inherited wife, so it is important to provide the surgeon with culturally sensitive info. Since all fam members speakEnglish, there is no need for a translator. |
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