Hesi fundamentals v1 questions with answers and rationales PDF

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HESI Fundamentals V1 Questions and Answers 1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved? a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infection rate. d. Rate of needle-stick injuries by nurse.

Acrylic nails are known to carry loads of bacteria and increase the risk of healthcare-associated infections. Therefore, by banning the wearing of acrylic nails, you would expect the prevalence of healthcare-associated infections to decrease. Acrylic nails have nothing to do with staff induced injuries, needle-stick injuries, or patient satisfaction scores.

2. Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? A) Aspirating gastric contents to assure a pH value of 4 or less. This is a method used to determine proper placement of NG tubing, but not the most accurate. B) Hearing air pass in the stomach after injecting air into the tubing. This is a method used to determine proper placement of NG tubing, but not the most accurate. C) Examining a chest x-ray obtained after the tubing was inserted. After placing an NG-tube, the placement of the tube is confirmed via x-ray since it is the most accurate way to ensure the tube has not been placed in the lungs, which would pose an aspiration risk. D) Checking the remaining length of tubing to ensure that the correct length was inserted. This is not an indicator of proper placement. You could very well be in a lung.

3. The father of an 11-year-old client reports to the nurse that the client has been “wetting the bed” since the passing of his mother and is concerned. Which action is most important for the nurse to enact? A. Reassure the father that it is normal for a pre-teen to wet the bed during puberty B. Inform the father that nocturnal emissions are abnormal and his son is developmentally

delayed C. Inform the father that it is most important to let the son know that nocturnal emissions are normal after trauma D. Refer the father and the client to a psychologist

It is common for adolescents to regress in their biological progression after experiencing a severe trauma, like losing a parent, sibling, or friend. While uncomfortable for the adolescent and parent, it is nothing to be concerned for. Often times, as the patient grieves or comes to terms with the trauma, the nocturnal emissions will cease.

4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

A. Assess the client for confusion and reteach the procedure B. Check the urine for color and texture C. Empty the urinal contents into the 24-hour collection container D. Discard the contents of the urinal

An “older adult male” in the question may imply that the patient may have an altered mental status or be demented. While suggesting, it is not directly stated, therefore (A) is inappropriate. (B) is incorrect because the lab will be assessing the collection specimen after the test is complete. (C) is correct because the nurse should first discard the first specimen, then begin to collect and record the time the first urine specimen was collected. It is important to have strict documentation for output, and to collect every urine specimen within that 24 hour period, otherwise the test must be restarted. (D) defeats the purpose of the 24-hour urine collection test.

5. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to most beneficial? A. Ask her how she would like to participate in the client’s care. B. Provide the wife with information about hospice C. Encourage the wife to visit after painful treatments are completed D. Refer her to support group for family members of those dying of cancer While the client’s wife may be grieving and need support, the priority for the client and client’s wife is to make sure the wife feels comfortable participating in the client’s care, if at all. Most people have an easier time coming to terms with the death of a loved one when they are involved in their care. (D) is a nice gesture, but will be more appropriate at a later time.

6. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first? A. Plan low carbohydrate and high protein meals B. Engage in strenuous activity for an hour daily C. Keep a record of food and drinks consumed daily D. Participated in a group exercise class 3 times a week

BMI of 30 indicates the patient is obese. (A) While a good step, it is not what should be completed first. (B) While a good step, it is not what should be completed first. (C) The best

thing to recommend is to have the patient keep a food journal to be able to go back and track their calorie intake; it may be helpful when meal planning or creating a workout routine plan. (D) Would be appropriate later.

7. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? (Select all that apply). A. Tops of the ear B. Bridge of the nose C. Around the nostrils D. Over the cheeks E. Across the forehead

This is proper placement of a nasal cannula. Constant pressure from the tubing may create skin damage to the areas of skin and bony prominences the nasal cannula will be resting on.

8. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take? a. Remove the basin of water from the client’s bed immediately b. Remind the UAP to dry between the client’s toes completely c. Advise the UAP that this procedure is damaging to the skin d. Add skin cream to the basin of water while the foot is soaking

(B) is especially important in making sure the patient does not experience skin breakdown due to excessive moisture. Keeping the client’s feet clean is necessary, but keeping the client’s feet dry is extremely important in skin maintenance.

9. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the nurse implement? a. Communicate the colleague’s actions to the unit charge nurse b. Send an email to facility administration reporting the action c. Write an anonymous complaint to a professional website d. Post a comment about the action on a staff discussion board

Looking up patients who are not under your direct care is a HIPPA violation and may result in termination of employment, despite the patient’s status in society or your curiosity. The first action to implement is to report to your Charge Nurse so he or she may report the incident to the appropriate chain of command.

10. At 0100 on a male client’s second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement? a. Leave the room and close the door to the client’s room b. Assess the appearance of the client’s surgical dressing c. Bring the client a prescribed PRN sedative-hypnotic

d. Discuss symptoms of sleep deprivation with the client

Although the patient has stated he is unable to sleep, the patient has also stated he has a plan, “to read until feeling sleep”, which implies the patient plans to sleep. Therefore, (D) is not necessary and (C ) is very unnecessary because it is a stronger sleep aid. Offering melatonin would be more appropriate, but since it is not an option, (A) is correct. (B) does not help the client sleep in any way.

11. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? a. Remove identifying information of the clients who participated

b. Recall that authored content may be legally discoverable c. Share material from credible, peer reviewed sources only d. Respect all copyright laws when adding website content

Since the improvement project is being creating on a social media platform, it is imperative to have all names and patient identifiers removed to protect the client’s identity and privacy. Any names posted, regardless of whether or not it is a social media platform or a peer-reviewed source is a HIPPA violation.

12. A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? a. Answer the client’s specific questions with a short understandable explanation b. Postpone the procedure until the client understands the risks and benefits c. Call the client’s next of kin and ask them to provide verbal consent d. Page the healthcare provider to return and provide additional explanation

A patient should not sign a consent if they do not completely understand the procedure, benefits and risks. Although you may have an understanding of the procedure, it is the Physician and physician ONLY who can review the process of the procedure and benefits/risks with the client. That task is out of your scope as an RN.

13. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? a. Tilt the pelvis forwards and backwards b. Bend the arm by flexing the ulnar to the humerus c. Turn the head to the right and left d. Extend the arm at the ide and rotate in circles

Active range of motion is when the patient is completing the physical activity with physical assistance or manipulation from the nurse. The elbow is a hinge joint, as stated in the question, and should be exercised by bending the forearm (ulnar) to the humerus (bicep area).

14. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? a. Access for side effects of the medication. b. Document the client’s responses. c. Complete a medication error report. d. Determine if the pain was relieved. This is a medication error. The first step in addressing a medication error is to access for any side effects of the medication on the patient. Certain analgesics may cause respiratory depression, so it is essential to monitor for vital sign changes or respiratory distress. Once noting the patient is stable, you may then contact the provider, document the response, and complete a medication error report.

15. When assessing a male client, the nurse finds that he is fatigued, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which? a. Hyperphosphatemia- muscle cramps, tetany, and perioral numbness or tingling b. Hypocalcemia - paresthesia, muscle spasms, cramps, tetany, numbness, and seizures c. Hypermagnesemia - (levels greater than 12 mmol/dL) can lead to cardiovascular complications (hypotension, and arrhythmias) and neurological disorder (confusion and lethargy) d. Hypokalemia- muscle weakness, leg cramps, and cardiac dysrhythmias. Normal range is 3.55.0.

16. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? a. Obtain a prescription from the healthcare provider regarding visitation privileges b. Request a consultation with the ethics committee for resolution of the situation c. Encourage the client to speak with her husband regarding his disruptive behavior d. Communicate the client’s wishes to all members of the multidisciplinary team

(A) is not appropriate. (C) would cause excessive stress to the patient and the patient may not want to see her estranged husband at all. (D) while appropriate, it does not help calm the estranged husband or get him off the premises. (B) is most appropriate and professionals who are trained in ethical issues like this can take care of the situation.

17. When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first? a. Determine pulse pressure b. Auscultate heart sounds c. Measure oxygen saturation d. Check for neck vein distention

Using accessory neck muscles during respirations is a serious sign of respiratory distress. The patient is a having a hard time breathing and as such, the first thing to do would be to measure oxygen saturation. (A) Pulse pressure is the difference between systolic and diastolic blood pressure. It is measured in millimeters of mercury (mmHg). It represents the force that the heart generates each time it contracts. (B) This has nothing to do with the heart. (D) Neck vein distention that is present is a sign of increased CVP (force on the aorta) and is not appropriate here.

18. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? a. Ventrogluteal b. Outer upper quadrant of the buttock c. Two inches below the acromion process

d. Vastus lateralis

2-3mL IM injections should always be made in the ventrogluteal area to minimize discomfort.

19. Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? a. Monitor daily urine output volume b. Drink plenty of water whenever thirsty c. Use salt tablets for sodium content d. Review food labels for sodium content

Hypernatremia is when a patient has a Sodium level that is too high, therefore it is most appropriate to teach the patient to check sodium levels on food labels before discharging. (A) While a high sodium level can decrease urine output, it is most important for the patient to be able to identify high sodium foods to decrease the risk of developing hypernatremia again. (B) Drinking too much water when thirsty can cause hyponatremia. (C) is incorrect because the patient is already at risk for developing high sodium levels again.

20. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take? A. Force oral fluids B. Request a nutrition consult C. Initiate contact precautions D. Limit visitors to immediate family only

MRSA is a type of antibiotic resistant bacteria and a patient with this should be placed on contact precautions. (A) oral fluids will not help rid the patient of the infection. (B) nor nutrition. (D) limiting visitors to immediate family is not necessary as anyone is at risk for contracting MRSA from an infected wound.

21. To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement?

a. Assess the client for health alterations that may be impacted by the effects of the medication b. Teach the client how to administer the medication to promote the best absorption c. Administer a half dose and observe the client for side effects before administering a full dosage d. Encourage the client to drink plenty of fluids to promote effective drug distribution

Before a new medication is given, an initial assessment should be completed to create a baseline for the patient; then the RN will be able to re-evaluate the patient and see if there have been any health alterations caused by the new medication. (B) this has nothing to do with potential side effects. (C) You should always administer a new medication as prescribed by the MD. (D) The amount of fluids the patient drinks will not affect the drug distribution in the body.

22. A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? a. Instruct the client to use guided imagery and slow rhythmic breathing b. Provide at least 20 minutes of back massage and gentle effleurage c. Encourage the client to watch TV. d. Place a hot water circulation device, such as an Aqua K pad, to operative site

If there are no other PRN pain medications available after an initial dose was given, it is most appropriate to call the provider, then switch to alternative pain management methods; like guided imagery and encouraging slow rhythmic breathing. (B) while massage may be helpful, it is inappropriate for incisional pain as it may open the sutures. (C) While distraction can help reduce pain, watching TV does not rid the patient of the pain. (D) NEVER place a circulation device on an operative site as it may open the sutures!

23. A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only] 4 tablets

40 mg BID (BID is 2 times a day). So 40mg x 2 = 80mg/day. 80 mg day/20mg tablets available = 4 tablets a day.

24. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? a. Establish a toileting schedule to decrease episodes of incontinence b. Complete a functional assessment of the client’s self-care abilities c. Apply a barrier ointment to intact areas that may be exposed to moisture d. Determine the size and depth of skin breakdown over the sacral area

Before you can treat the skin breakdown, you must first measure and record the affected area so you can have something to compare after you begin your interventions/treatments. Then you can continue with (A)(B) and (C).

25. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? a. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record b. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace c. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically d. Completing the electronic record during an interview is a legal obligation of the examining nurse

While looking at the computer, the RN may have limited ability to visualize the nonverbal communication from the patient. (A) you should be trying to initiate some, not constant eye contact with your patient while completing electronic documentation. (B) The patient can speak at a normal pace with or without HER. (D) while the electronic record during a...