Page 1 of 195
HESI FUNDAMENTALS TEST BANK
EXAM
NEWEST ACTUAL EXAM QUESTIONS
AND
CORRECT DETAILED ANSWERS
The nurse in a geriatric clinic collects the following information from an
82-year-old patient and her daughter, the family caregiver. The daughter
explains that the patient is "always getting lost." The patient sits in the
chair but gets up frequently and paces back and forth in the examination
room. The daughter says, "I just don't know what to do because I worry
she will fall or hurt herself." The daughter states that, when she took her
mother to the store, they became separated, and the mother couldn't find
the front entrance. The daughter works part time
and has no one to help watch her mother. Which of the data form a
cluster, showing a relevant pattern? (Select all that apply) [17]
1. Daughter's concern of mother's risk for injury
2. Pacing
3. Patient getting lost easily
4. Daughter working part time
,Page 2 of 195
5. Getting up frequently - ✔✔✔ Correct Answer > 2, 3, 5
Which of the following are examples of collaborative problems?
(Select all that apply) [17]
1. Nausea
2. Hemorrhage
3. Wound infection
4. Fear - ✔✔✔ Correct Answer > 2, 3
Two nurses are having a discussion at the nurses' station. One nurse is a
new graduate who added, "Patient needs improved bowel function
related to constipation" to a patient's care plan. The nurse's colleague,
the charge nurse says, "I think your diagnosis is possibly worded
incorrectly. Let's go over it together." A correctly worded diagnostic
statement is: [17]
1. Need for improved bowel function related to change in diet
2. Patient needs improved function related to alteration in elimination
3. Constipation related to inadequate fluid intake
4. Constipation related to hard infrequent stools - ✔✔✔ Correct
Answer > 3
,Page 3 of 195
The following nursing diagnoses all apply to one patient. As the nurse
adds these diagnoses to the care plan, which diagnoses will not include
defining characteristics? [17]
1. Risk for aspiration
2. Acute confusion
3. Readiness for enhanced coping
4. Sedentary lifestyle - ✔✔✔ Correct Answer > 1
A nurse is assigned to a patient who has returned from the recovery
room following surgery for a colorectal tumor. After an initial
assessment the nurse anticipates the need to monitor the patient's
abdominal dressing, IV infusion, and function of drainage tubes. The
patient is in pain, reporting 6 on a scale of 010, and will not be able to
eat or drink until intestinal function returns. The family has been in the
waiting room for an hour, wanting to see the patient. The nurse
establishes priorities first for which of the following situations? (Select
all that apply) [18]
1. The family comes to visit the patient
2. The patient expresses concern about pain control
3. The patient's vital signs change, showing a drop in blood
pressure.
4. The charge nurse approaches the nurse and requests a report at end of
shift. - ✔✔✔ Correct Answer > 2, 3
, Page 4 of 195
A patient signals the nurse by turning on the call light. The nurse enters
the room and finds the patient's drainage tube disconnected, 100 mL of
fluid in the IV line, and the patient asking to be turned. Which of the
following does the nurse perform first?
[18]
1. Reconnect the drainage tube
2. Inspect the condition of the IV dressing
3. Improve the patient's comfort and turn her onto her side
4. Obtain the next IV fluid bag from the medication room - ✔✔✔
Correct Answer > 1
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9
kg) and is partially immobilized because of a stroke. The nurse turns the
patient and finds that the skin over the sacrum is very red and the patient
does not feel sensation in the area. The patient has had fecal
incontinence on and off for the last 2 days. The nurse identifies the
nursing diagnosis of "risk for impaired skin integrity." Which of the
following goals are appropriate for the patient? (Select all that apply)
[18]
1. Patient will be turned every 2 hours within 24 hours
2. Patient will have normal bowel function within 72 hours
3. Patient's skin will remain intact through discharge
4. Patient's skin condition will improve by discharge - ✔✔✔
HESI FUNDAMENTALS TEST BANK
EXAM
NEWEST ACTUAL EXAM QUESTIONS
AND
CORRECT DETAILED ANSWERS
The nurse in a geriatric clinic collects the following information from an
82-year-old patient and her daughter, the family caregiver. The daughter
explains that the patient is "always getting lost." The patient sits in the
chair but gets up frequently and paces back and forth in the examination
room. The daughter says, "I just don't know what to do because I worry
she will fall or hurt herself." The daughter states that, when she took her
mother to the store, they became separated, and the mother couldn't find
the front entrance. The daughter works part time
and has no one to help watch her mother. Which of the data form a
cluster, showing a relevant pattern? (Select all that apply) [17]
1. Daughter's concern of mother's risk for injury
2. Pacing
3. Patient getting lost easily
4. Daughter working part time
,Page 2 of 195
5. Getting up frequently - ✔✔✔ Correct Answer > 2, 3, 5
Which of the following are examples of collaborative problems?
(Select all that apply) [17]
1. Nausea
2. Hemorrhage
3. Wound infection
4. Fear - ✔✔✔ Correct Answer > 2, 3
Two nurses are having a discussion at the nurses' station. One nurse is a
new graduate who added, "Patient needs improved bowel function
related to constipation" to a patient's care plan. The nurse's colleague,
the charge nurse says, "I think your diagnosis is possibly worded
incorrectly. Let's go over it together." A correctly worded diagnostic
statement is: [17]
1. Need for improved bowel function related to change in diet
2. Patient needs improved function related to alteration in elimination
3. Constipation related to inadequate fluid intake
4. Constipation related to hard infrequent stools - ✔✔✔ Correct
Answer > 3
,Page 3 of 195
The following nursing diagnoses all apply to one patient. As the nurse
adds these diagnoses to the care plan, which diagnoses will not include
defining characteristics? [17]
1. Risk for aspiration
2. Acute confusion
3. Readiness for enhanced coping
4. Sedentary lifestyle - ✔✔✔ Correct Answer > 1
A nurse is assigned to a patient who has returned from the recovery
room following surgery for a colorectal tumor. After an initial
assessment the nurse anticipates the need to monitor the patient's
abdominal dressing, IV infusion, and function of drainage tubes. The
patient is in pain, reporting 6 on a scale of 010, and will not be able to
eat or drink until intestinal function returns. The family has been in the
waiting room for an hour, wanting to see the patient. The nurse
establishes priorities first for which of the following situations? (Select
all that apply) [18]
1. The family comes to visit the patient
2. The patient expresses concern about pain control
3. The patient's vital signs change, showing a drop in blood
pressure.
4. The charge nurse approaches the nurse and requests a report at end of
shift. - ✔✔✔ Correct Answer > 2, 3
, Page 4 of 195
A patient signals the nurse by turning on the call light. The nurse enters
the room and finds the patient's drainage tube disconnected, 100 mL of
fluid in the IV line, and the patient asking to be turned. Which of the
following does the nurse perform first?
[18]
1. Reconnect the drainage tube
2. Inspect the condition of the IV dressing
3. Improve the patient's comfort and turn her onto her side
4. Obtain the next IV fluid bag from the medication room - ✔✔✔
Correct Answer > 1
A nurse assesses a 78-year-old patient who weighs 240 pounds (108.9
kg) and is partially immobilized because of a stroke. The nurse turns the
patient and finds that the skin over the sacrum is very red and the patient
does not feel sensation in the area. The patient has had fecal
incontinence on and off for the last 2 days. The nurse identifies the
nursing diagnosis of "risk for impaired skin integrity." Which of the
following goals are appropriate for the patient? (Select all that apply)
[18]
1. Patient will be turned every 2 hours within 24 hours
2. Patient will have normal bowel function within 72 hours
3. Patient's skin will remain intact through discharge
4. Patient's skin condition will improve by discharge - ✔✔✔
