NEW HESI RN FUNDAMENTALS

SAMPLE QUESTIONS/DESCRIPTION/PREVIEW - The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? exchange pulse ox for another monitor - Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse to include in the client’s plan of care? The client will Ambulate without discomfort -After assessing a client, the nurse identifies three nursing problems. When developing the client’s plan of care, which action should the nurse take next? Prioritize the identified nursing diagnoses The nurse is discharging an adult woman who was hospitalized for 5 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement? Provide written instructions that are easy to follow. 1. Which assessment finding is most significant in determining the level of assistance a client needs with personal care? Disorientation to time, place, and person 2. Eight hours after the removal of an indwelling catheter, a male client reports low abdominal pain, and palpation of the bladder indicates that it is distended and dull percussion. Even after assistingthe client to a standing position, he is unable to void. What action should the nurse take? Prepare to reinsert the urinary catheter. 3. The nurse notices a male client grimacing as he moves from the bed to a chair, but when asked about his pain he denies having any pain. Which intervention should the nurse implement first? Askthe client what is making him grimace. 4. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first? Respiratory rate 5. The charge nurse observes a new graduate nurse demonstrate the administration of two differentliquid medications through a gastrostomy tube used for continuous feeding, as seen in the video. What actions should the nurse take? (SATA) Confirm that the nurse determined the amount of gastric residualAdd the liquid volumes when documenting fluid intake Instruct the nurse to administer each mediation separately 6. The nurse inserts a catheter for nasotracheal suctioning as seen in the picture. What action shouldthe nurse take nest? Apply intermittent suction 7. A client who is 2 days postoperative for thoracic surgery is complaining of incisional pain 2 hours after receiving his pain medication. He rates his pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, what action should the nurse implement? Instruct the client to use guided imagery and slow rhythmic breathing. 8. Am unlicensed assistive personnel (UAP) is assigned to help a female client with her bath who has viral hepatitis A and hepatic encephalopathy. What information should the nurse reinforce with the UAP? Wear gloves while giving a bath 9. The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures? Puts on new gloves when entering a client’s room. 10. The nurse is planning care for a group of clients during the night shift on a medical unit. Which client should be assessed regularly during the night for sleep apnea? An older male with multiple problems, including obesity, diabetes, and hypertension. 11. It is most important for the nurse to recalculate the Braden scale for a client who has developed which problem? Urinary incontinence 12. A male client with a sprained ankle is seen at the clinic and is given a pair of crutches. When the client stands with the aid of the crutches, the nurse notes a space of three finger-widths betweenthe top of the crutch and the client’s axilla. What action should the nurse take? Proceed with teaching the client how to walk with the crutches. 13. After experiencing symptoms caused by an abnormal heart rhythm, a client is placed on a temporary pacemaker. When the client expresses concern and fear of the pacemaker, how shouldthe nurse respond? Encourage discussion about the concern and fears. 14. Prior to initiating digital removal of a fecal impaction, it is important for the nurse to perform which client assessment? Vital signs 15. The mother of a child with Tetrology of Fallot ask the nurse, “ Why did this happen to my baby? What did I do wrong?” Which response is most helpful? “This must be a very difficult time for you.” 16. The healthcare provider prescribes bladder irrigation to maintain patency of a client’s indwelling urinary catheter. Which intervention should the nurse implement? Use sterile syringe to irrigate the normal saline 20 ml 17. Two nurses assess a client for a pulse deficit and count an apical pulse for 72 beats/minute and a radial pulse of 88 beats/minute. What action should the nurses take? Obtain a second pulse deficit reading 18. A female who is 1 day post mastectomy is crying when the nurse enters the room. What action should the nurse take? Stay with the client in silence while touching her forearm 19. A 24-hour urine collection is in progress. The client tells the nurse that the last voiding was accidentally flushed instead of saving in the container. What intervention should the nurse initiate? Discard the urine and start another 24-hour period 20. A confused elderly male client is having trouble sleeping at night and is sometimes found wandering the hallway. What nursing intervention should the nurse implement first? Provide a back rub at bedtime 21. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has agood prognosis and refuses to write a “do not resuscitate” (DNR) prescription. What action should the nurse take? Initiate an ethics committee review of the case 22. The nurse is preparing to feed a newly admitted elderly male client who is debilitated, but is ableto respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain? Client's ability to chew and swallow 23. The nurse enters the room of a client with a Clostridium difficile infection to administer an intravenous antibiotic. The unlicensed assistive personnel (UAP) is in the room cleaning the client’sbuttocks and states the client has been incontinent with diarrhea. The UAP is wearing gloves but not a gown. What action should the nurse implement first? Tell UAP put a gown on 24. The computer documentation system shuts down while the nurse is entering the client’s physical assessment data. What should the nurse do first? Wait for notification services department of the situation 25. In assessing a client who has a nursing diagnosis ofspiritual distress, which action should thenurse take first? Assist and support the client in establishing short-term goals. 26. During transfer to the medical unit, a client who experienced an acute change in level of consciousness became increasingly confused and combative, justifying soft wrist restraints for the client’s upper and lower extremities. Which intervention is most important for the nurse to implement on admission? Determine baseline neuro status 27. (PICTURE OF EAR AND EAR DROPS) The nurse prepares to administer ear drops to an adolescent client as seen in the picture. What should the nurse do next? Pull ear auricle downward 28. The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply)Retake the pt's Bp in opposite arm** Determine the pt's activity and feelings prior to bp measurement 29. A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his leg. Which actin should the nurse implement? Instruct pt to flex both of his feet several times a day 30. Which information is most important for the nurse to consider when preparing to transfer a client from the bed to a chair? The pt's ability to bear weight on lower extremities 31. The nurse is assessing a client with chronic obstructive pulmonary disease (COPD). The pulse oximeter alarm is flashing without displaying a percentage of oxygen. Which action should the nurse implement? exchange pulse ox for another monitor 32. Two days after surgery a male client experiences incisional pain while dangling his feet at the bedside and he refuses to ambulate as prescribed. The nurse establishes a problem of, “Activity intolerance related to pain.” Based in this problem, which outcome statement is best for the nurse to include in the client’s plan of care? The client will Ambulate without discomfort 33. After assessing a client, the nurse identifies three nursing problems. When developing the client’s plan of care, which action should the nurse take next? Prioritize the identified nursing diagnoses 34. After reviewing the admission assessment of a client with chronic pain, which interventions should the nurse include in this client’s plan of care? (Select all that apply) Provide comfort measures such as topical warm application and tactile massageImplement a 24h schedule of routine administration of prescribed analgesic Determine client's subjective measure of pain using a numerical pain scale 35. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan of care to reduce the client’s risk for infection related to the catheter? Encourage increased intake of oral fluids 36. The electronic medication system alerts the nurse that the medication dose scanned is two times higher than the dose prescribed. What action should the nurse implement? Convert the dose on hand to match the prescribed dose 37. A male client with chronic debilitating heart disease asks the nurse to help him die because he believes that he will be better off dead rather than living under the current circumstances. The nurse supports the client and considers providing the family with a does of medications that can result in the client’s death. If the nurse acts on this intention, what is the most likely consequence?The nurse will be prosecuted for the murder of the pt 38. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding? Complete the intermittent suction of nasopharynx 39. The grandmother of a young adult male admitted to the psychiatric unit yesterday requests information about her grandson’s treatment plan. Before answering the family member’s question, what action should the nurse take? Ensure that the signed release of info includes thegrandmother 40. When providing health teaching to elderly clients, what action is most important for the nurse to implement? Use everyday language when explaining issue 41. A male client presents to the clinic stating that he has a high stress job and is having difficulty falling asleep at night. The client complains of a constant headache and is seeking medication to help him sleep. Which intervention should the nurse implement? Determine the client's sleep andactivity pattern 42. To assess the quality of an adult client’s pain. What approach should the nurse use? Ask the pt to describe pain 43. The nurse is planning a weight reduction teaching program to be implemented at a community health center. Which goal is best for clients who are approximately fifteen percent over their ideal wight and wish to participate in the weight loss program? Fat intake between 20 to 30 percent of total daily intake 44. The nurse prepares to irrigate the ear of an adult client. The client is positioned with the head tilted slightly toward the affected side and the emesis basin positioned under the ear. What actionshould the nurse take next? confirm the temperature of the irrigation solution 45. The home health nurse visits a client who has a serum sodium level of 123 mEq/L. To explore possible etiologies for this value, what questions should the nurse ask the client? How much waterand ice chips do you have each day? 46. The healthcare provider prescribes hydroxyzine (Vistaril) 35 mg IM for a client who is vomiting. The available drug is labeled, 50 mg/ml. How many ml should the nurse administer? 0.7ml 47. The nurse finds a confused female client wandering in the hallway during the night. What actionshould the nurse implement? (Select all that apply) Raise the side rails of bed Escort her back to room Secure bed alarm on mattress 48. A client in the outpatient clinic complains of experiencing hard, infrequent stools. Which instruction should the nurse provide this client? Drink 6-8 large glasses of water daily 49. The nurse reviews discharge instructions for a male client with obstructive sleep apnea syndrome (OSAS). The client tells the nurse that he likes to drink a glass of wine before going to bed. How should the nurse respond? Offer to contact healthcare provider about a prescription for a sleepingaid 50. The home care nurse has identified the problem “Risk for hopelessness” for a male client who is terminally ill with a life expectancy for several days. Which instruction should the nurse provide the client’s spouse? Listen for changes in what the client hopes for and try to help meet his goals 51. The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client’s auricle upand back and prepares the thermometer. What action should the nurse implement? A Demonstrate the correct technique for pulling the ear down and back 52. A journalist asks the nurse working in the Emergency Department about condition of a local politician recently admitted to the medical center following a publicly reported building fire. What action should the nurse take? Obtain verbal consent from family member before discussing the client’s condition 53. Which outcome statement can be used in the planning stage of the nursing process? The clientwill demonstrate ability to change ostomy bag in two days 54. The nurse observes an adult woman perform a return demonstration of diaphragmatic breathing. The client inhales while holding her abdomen, then removes her hand to allow expansion of the abdomen during exhalation. What action should the nurse take after observing the client’s demonstration? Demonstrate how to expand the abdomen while inhaling and let it sink in while exhaling 55. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next? Observe the suctioned secretions 56. The nurse is evaluating the fluid balance of a client who was admitted yesterday with dehydration and who has been receiving IV fluidssince admission. An increased in which parameter indicatestothe nurse that the client is rehydrating? Pulse rate 57. The charge nurse is observing a new graduate’s performance of wound care. Which technique indicates that the employee is effectively cleansing the wound? Starts at wound site and moves outward using circular motions 58. While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Whataction should the nurse take in response to this finding? Provide the client an incentive spirometerto increase respiratory effort 59. What assessment is most important for the nurse to perform to the application of a heating pad? Degree of neurosensory impairment 60. The healthcare provider prescribes acetaminophen (Tylenol) elixir 325 mg PO for an older adult who has difficulty swallowing pills. The available oral solution is labeled, acetaminophen elixir 325mg/5ml. How many teaspoons should the nurse administer with each does? 1 teaspoon 61. An elderly woman comesto the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? The importance of using vaginal lubricants. 62. A client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact?A daughter in law designated as the client’s Durable power of Attorney (DPOA) 63. The unlicensed assistive personnel (UAP) describe the appearance of the bowel movement of several clients. Which description warrant additional follow-up be the nurse? (Select all that apply) multiple hard pellets, tarry appearance, and brown liquid -I ALSO ADVISE YOU TO STUDY THIS 2018/2019 FILE-MOST SCHOOLS ARE USING THIS!!!!! 1. A client at an outpatient clinic submits a clean- catch midstream urine specimen for a routine urinalysis. In later review of the client's medical record, which data indicates to the nurse that the specimen collection should be repeated? A. The urine specimen shows multiple organisms in low colony counts. B. The client reported eating a meal before voiding the urine specimen C. There was a total of 30 ml of urine voided into the specimen cup D. The medical record indicates the client is allergic to most antibiotics 2. When assessing a client who starts to wheeze which related data should the nurse obtain? A. Precipitating factors B. Body Temperature C. Presence of radiation D. Heart sounds 3. A client diagnosed with primary open-angle glaucoma received a prescription for miotic eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to include in this client’s teaching? A. “Administer the medication directly on the cornea.” B. “Wash your hands after each administration of eye drops.” C. “Do not allow the dropper bottle to touch the eye.” D. “Squeeze your eye closed after administering the drops.” 4. The nurse observes that a male client on a clear liquid diet has a cup of coffee on his breakfast tray. What action should the nurse implement? A. Consult with the dietician to learn if the client is allowed to drink coffee B. Determine which member of the nursing staff brought the cup of coffee to the client C. Remind the client that no milk, or creamer can be added to the coffee. D. Remove the coffee from the tray, advising the client that it is not included in the diet. 5. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care. What action should the nurse take next? A. Determine if the expected outcomes were realistic B. Modify the nursing interventions to achieve the client’s goals C. Obtain current client data to compare with expected outcomes D. Review related professional standards of care. 6. The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. In designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use? A. Return demonstration B. Journaling C. Analogies D. Role playing 7. The nurse observes the skin over a client's greater trochanter as seen in the picture. What actions should the nurse implement? (select all that apply) A. Remove the eschar before applying and securing a hydrocolliod B. Prepare to implement a pressure redistribution mattress C. Obtain a specimen of the site for culture and sensitivity D. Instruct the Unlicensed assistive personnel to frequently offer oral fluids E. Explain to the client that the wound needs debridement 8. The nurse has removed the barbiturate capsule from the unit dose wrapper to administer to a male client. The client decides he wants to watch a television program and requests not to take the medication. Which action should the nurse implement? A. Credit the medication back and put in the client’s medication box B. Keep the medication and see if the client will want to take it later. C. Have another nurse watch disposal of the medication into disposal container D. Explain that since the medication is a controlled substance it must be taken. 9. The home health nurse is reviewing the personal care needs of an elderly client who lives alone. Which client assessment findings indicate the need to assign an unlicensed assistive personal (UAP) to provide routine foot care and file the client’s toenails? (Select all that apply). A. Shuffling gait. B.Diminished visual acuity. C. Syncope when bending. D. hands tremors. E.Urinary incontinence 10. The charge nurse observes a new graduate's performance of wound care. Which technique indicates that the employee is effectively cleansing the wound? A. Starts at the wound site and moves outward using circular motions. B. Cleanses from the outer area of the wound toward the center C. Uses a sterile swab to go over the wound site twice. D. Scrubs wound vigorously for at least two minutes 11. The nurse is evaluating the fluid balance of the client who was admitted yesterday with dehydration and who has been receiving iv fluids since admission. An increase in which parameter indicates to the nurse that the client is rehydrating. A. Serum haematocrit. B. Urine specific gravity. C. Pulse Rate. D. Urinary output. 12. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client verbalizes concerns about pain. What action should the nurse implement? a. Explain the respiratory problems that can occur with morphine use. b. Teach family how to evaluate the effectiveness of analgesics. c. Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump. d. Provide client with a schedule of around-the-clock prescribed analgesic use. 13. The nurse begins to suction a client’s oropharynx as seen in the picture. What action should the nurse take next? a. Position suction in the trachea. b. Apply nasal cannula oxygen. c. Insert a tongue blade. d. Observe the suction secretion. 14. 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 interview process is enhanced with electronic documentation and allows the client to speak at a normal pace. b. Completing the electronic record during an interview is a legal obligation of the examining nurse. c. The nurse has limited ability to observe non-verbal communication while entering the assessment electronically. d. The client’s comfort level is increased when the nurse breaks eye-contact to type notes into the record. 15. The nurse measures the client’s blood pressure(BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply). a. Determine the client’s activities and feelings prior to the BP measurement. b. Retake the Client's blood pressure in the opposite arm c. Assign the unlicensed assistive personnel to recheck the BP in an hour. (not the answer because it should be rechecked sooner) d. Ask another nurse to assist in assessing for an apical-radial pulse deficit. e. Immediately take two more readings on the same arm. 16. A male Native American presents to the clinic with complaints of frequent abdominal cramping and Nausea. He states that he has chronic constipation and has not had a bowel movement in 5 days, despite trying several home remedies. Which intervention is most important for the nurse to implement. a. Access for the presence of an impaction. b. Evaluate stool sample for the presence of blood. c. Obtain list of prescribed home medications. d. Determine what home remedies where used. 17. The Practice Nurse (PN) applies sterile gloves and opens a pack of sterile sponges to assist the healthcare provider with a bedside procedure. After the Charge Nurse (CN) observes the PN, what actions should the charge nurse take? a. Confirm that PN is ready to assist with the planned procedure. b. Obtain all new supplies and directly assist with the procedure. c. Remove the contaminated package of sponges from the table. d. Instruct the PN to remove the gloves that are now contaminated. 18. A male client with limited mobility is discharged with home-health services. When the home-health nurse arrives, the client asks what he can do for the swelling in his leg. What action should the nurse implement? a. Encourage the client to take short walks around the block. b. Advice the client to dangle his feet during meals and before bedtime. c. Ensure the clients to flex both of his feet, several times a day. d. Explain the need to keep the head of the bed elevated. 19. A male client with a recent diagnosis of terminal cancer, tells his nurse that he wishes to die naturally. The client states that he’s tired of fighting this illness and is only continuing treatment because of his family’s wishes. What actions should the nurse take? a. Request a consultation for a psychologist to talk with the client. b. Call a clergy to discuss end-of-life decisions with the client. c. Determine if he wants to stop radiation and chemotherapy. d. Arrange a meeting with the client, his family and the healthcare provider. 20. A male client who had emergency gallbladder surgery yesterday is getting ready for discharge. The nurse knows that the client speaks very little English. When teaching wound care, which method should the nurse use to evaluate the client’s understanding of self-care at home? a. Have the client demonstrate prescribed wound care. b. Provide written instructions in the client’s native language. c. Have an interpreter repeat the wound care instructions. d. After each instruction, ask the client if he understands. 21. 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. 22. The nurse is evaluating a client who is admitted to an adult medical unit, and notes that a client’s urine output has been 70 ml/hr. Which action should the nurse implement? a. Recommend drinking cranberry juice with meals. b. Encourage the client to drink more fluids. c. Document the client’s urinary output every hour. (NORMAL RANGE) d. Notify the healthcare provider immediately. 23. A client is admitted with Pneumonia and has a recent history of Methicilline-resistance Staphylococcus aureus (MRSA). The Client is placed in isolation while caring for the client, which client should the nurse place in a designated bio-hazard bag before it is removed from the room? a. A sputum specimen. (BODILY FLUIDS=BIOHAZARD) b. Paper mask and gown. c. The nurse’s stethoscope. d. Bed linens. 24. A client is receiving Ketorolac (Toradol) IM 45mg IM every 6 hours for post operative pain. The available 2ml vile is labeled, Toradol 30mg / ML. How many ML should the nurse administer? (enter numerical value only, If rounding is required round to the nearest Tenths). [1.5 x] 25. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs should the nurse obtain first. a. blood pressure. b. Respiratory rate. (Cyanosis caused by low oxygen levels in the RBCs) c. Pulse Rate. d. Temperature. 26. An older male client returns to the clinic for chronic pain management after taking morphine sulphate (MS contin) 25mg every 12hrs. He states he took the medication only when the pain was too severe to sleep. What action should the nurse implement? a. Explain the risk of drug addiction from long term pain medication. b. Tell the client to continue taking the MS contin with severe pain. c. Instruct the client to take the MS Contin every 12 hours as prescribed. d. Teach the client alternative ways to manage his chronic pain. 27. A client is admitted with complaints of shortness of breath (Dyspnea) on exertion, and chest pressure The healthcare provider prescribes a medication that is unfamiliar to the nurse. When checking the drug handbook, the nurse reads that the prescribed amount is an unusually large dose. What actions should the nurse take? a. Consult pharmacists for those clarification. b. Verify the prescribed dosage with a healthcare provider. c. Administer the medication as prescribed. d. Give the dosage recommended in the drug handbook. 28. A client who lives in an assisted living facility; develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should the nurse contact? a. The client’s youngest son was identified by family members as the family’s spokesperson. b. A daughter-in-law designated as the client’s durable power of attorney (DPOA) c. The client’s spouse who lives in the independent living unit of the facility. d. The client's oldest living child, a lawyer who is visiting from out of town. 29. What explanation is best for the nurse to provide a client who asked the purpose of using the log-rolling technique for turning? a. Working together can decrease the risk of back injury to the nurses. b. Turning instead of pulling reduces the likelihood of skin damage. c. The technique is intended to maintain straight spinal alignment. d. Using two or three people increases client’s safety. 30. The nurse is teaching a husband how to care for his wife who recently had a stroke and has residual weakness on her right side. What style shoes does the nurse recommend the client wear when ambulating with her husband’s assistance? a. Slip-on rubber shower shoes. b. Tennis shoes with Velcro. (FALL PRECAUTION) c. Rubber sole slippers. d. Leather sole loafers. 31. A young male client with testicular cancer has a living will that describes his desire that no extraordinary measures be taken to save his life. The healthcare provider knows the client has a good prognosis and refuses to write a “Do Not Resuscitate”(DNR Prescription). What actions should the nurse take? a. Ensure resuscitation equipment is available. b. Ask the family to review options with the client. c. Place a DNR bracelet on the client’s arm. d. Initiate an ethics committee review of the case. 32. A client newly diagnosed with stage 3 lung cancer becomes angry with the healthcare provider and nurs