Additional HESI Fundamentals
Recommended Sets Exam | 245 Questions
with 100% Original Verified Solutions, A+
Grade, Latest Update
1. 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 (2.8 mmol/L)
C. Preoperative chest x-ray report is not available
D. Client's pulse oximeter reading is 96%
Answer: B
*Rationale: A serum potassium of 2.8 mEq/L is critically low (normal 3.5-5.0).
Hypokalemia increases the risk of cardiac arrhythmias during anesthesia and
surgery. This requires immediate correction (IV potassium replacement) before
proceeding. The consent form, chest x-ray, and normal SpO2 are important but not
life-threatening.*
2. 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
Answer: C
Rationale: A sudden drop in blood pressure post-operatively may indicate internal
bleeding. The nurse should first assess the surgical dressing for bleeding or
distension. Deep breathing would not address hypotension; increasing frequency
or reviewing baseline delays intervention.
,3. 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
Answer: B
Rationale: A functioning AV fistula has a palpable thrill and audible bruit, and the
vein becomes enlarged (arterialized). Ecchymosis, redness, and pulselessness
indicate complications.
4. 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
Answer: C
Rationale: Elevating the head of the bed 6-8 inches (or using blocks) helps prevent
nocturnal reflux by using gravity to keep gastric contents in the stomach. Lying
down worsens reflux. High-fiber foods are generally beneficial. Antacids can be
used as needed.
5. 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
,Answer: B
*Rationale: Increased fluid intake (3 L/day) helps flush the bladder, prevent clot
formation, and reduce the risk of catheter obstruction. Driving is not specifically
restricted for 2 weeks. Spicy foods may irritate but not prohibited. The catheter
should not be clamped; it must drain freely.*
6. D - A client with chronic cirrhosis has esophageal varices. 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
Answer: D
Rationale: Esophageal varices are prone to rupture, causing life-threatening
upper GI bleeding. Hematemesis (vomiting blood) is a key sign of active bleeding.
Clay-colored stool suggests biliary obstruction; brown urine and anorexia are less
urgent.
7. 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 116/70 mmHg. 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
Answer: B
Rationale: ST elevation in multiple leads indicates acute myocardial infarction.
This is a life-threatening emergency requiring immediate intervention. Radiating
jaw pain is also concerning, but ECG changes are diagnostic and more critical.
, 8. 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
Answer: A
Rationale: Hyperthyroidism increases metabolic rate, leading to tachycardia,
palpitations, and increased pulse rate. Diarrhea may occur but is less common.
The thyroid gland is usually enlarged (goiter), not atrophied. Periorbital edema is
seen in hypothyroidism (myxedema).
9. 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
Answer: D
Rationale: According to the image, the correct answer is D. However, clinical
reasoning: Epididymitis caused by E. coli (enteric organism) often requires
antibiotic therapy; surgery is rarely indicated unless abscess or chronic. The
image indicates D, so we follow that.
10. 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
Recommended Sets Exam | 245 Questions
with 100% Original Verified Solutions, A+
Grade, Latest Update
1. 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 (2.8 mmol/L)
C. Preoperative chest x-ray report is not available
D. Client's pulse oximeter reading is 96%
Answer: B
*Rationale: A serum potassium of 2.8 mEq/L is critically low (normal 3.5-5.0).
Hypokalemia increases the risk of cardiac arrhythmias during anesthesia and
surgery. This requires immediate correction (IV potassium replacement) before
proceeding. The consent form, chest x-ray, and normal SpO2 are important but not
life-threatening.*
2. 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
Answer: C
Rationale: A sudden drop in blood pressure post-operatively may indicate internal
bleeding. The nurse should first assess the surgical dressing for bleeding or
distension. Deep breathing would not address hypotension; increasing frequency
or reviewing baseline delays intervention.
,3. 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
Answer: B
Rationale: A functioning AV fistula has a palpable thrill and audible bruit, and the
vein becomes enlarged (arterialized). Ecchymosis, redness, and pulselessness
indicate complications.
4. 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
Answer: C
Rationale: Elevating the head of the bed 6-8 inches (or using blocks) helps prevent
nocturnal reflux by using gravity to keep gastric contents in the stomach. Lying
down worsens reflux. High-fiber foods are generally beneficial. Antacids can be
used as needed.
5. 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
,Answer: B
*Rationale: Increased fluid intake (3 L/day) helps flush the bladder, prevent clot
formation, and reduce the risk of catheter obstruction. Driving is not specifically
restricted for 2 weeks. Spicy foods may irritate but not prohibited. The catheter
should not be clamped; it must drain freely.*
6. D - A client with chronic cirrhosis has esophageal varices. 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
Answer: D
Rationale: Esophageal varices are prone to rupture, causing life-threatening
upper GI bleeding. Hematemesis (vomiting blood) is a key sign of active bleeding.
Clay-colored stool suggests biliary obstruction; brown urine and anorexia are less
urgent.
7. 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 116/70 mmHg. 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
Answer: B
Rationale: ST elevation in multiple leads indicates acute myocardial infarction.
This is a life-threatening emergency requiring immediate intervention. Radiating
jaw pain is also concerning, but ECG changes are diagnostic and more critical.
, 8. 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
Answer: A
Rationale: Hyperthyroidism increases metabolic rate, leading to tachycardia,
palpitations, and increased pulse rate. Diarrhea may occur but is less common.
The thyroid gland is usually enlarged (goiter), not atrophied. Periorbital edema is
seen in hypothyroidism (myxedema).
9. 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
Answer: D
Rationale: According to the image, the correct answer is D. However, clinical
reasoning: Epididymitis caused by E. coli (enteric organism) often requires
antibiotic therapy; surgery is rarely indicated unless abscess or chronic. The
image indicates D, so we follow that.
10. 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
