Grand Canyon University - HESI Practice Exam Fundamentals Nursing Car
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Practice Test Assessment Performance
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Let's review your results from 3/26/2022 at 6:50 pm MST
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A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of bed for the
first time, the client becomes dizzy. What action should the nurse implement?
Encourage the client to take several slow, deep breaths while ambulating.
Help the client to remain standing by the bedside until the dizziness is relieved.
Instruct the client to remain on bedrest until the healthcare provider is contacted.
Advise the client to sit on the side of the bed for a few minutes before standing
again.
Rationale
The nurse should implement (D), because orthostatic hypotension is a common
result of immobilization, causing the client to feel dizzy when first getting out of
bed following a period of bedrest. To prevent this problem, it is helpful to have the
body acclimate to a standing position by sitting upright for a short period (D)
before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B)
may result in a loss of consciousness. (C) is not indicated and will increase the
potential for complications associated with prolonged immobility.
Which client assessment data is most important for the nurse to consider before
ambulating a postoperative client?
Respiratory rate.
Wound location.
Pedal pulses.
, Pain rating.
Rationale
Mobilization and ambulation increase oxygen use, so it is most important to
assess the client's respiratory rate (A) before ambulation to determine tolerance
for activity. (B, C, and D) are also important, but are of lower priority than (A).
A client is admitted with a stage four pressure ulcer that has a black, hardened
surface and a light-pink wound bed with a malodorous green drainage. Which
dressing is best for the nurse to use first?
Hydrogel.
Exudate absorber.
Wet to moist dressing.
Transparent adhesive film.
Rationale
To provide moisture and loosen the necrotic tissue, the eschar should be covered
first with wet to moist dressings (C), which are discontinued and then a hydrogel
alginate can be placed in the prepared wound bed to prevent further damage of
granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic
tissue of slough and rehydrates the wound bed, it does not address wicking the
purulent drainage from the wound. Exudate absorbers (B) provide a moist wound
surface, absorb exudate, and support debridement, but do not prepare the wound
bed for proper healing. Transparent dressings (D) are used to protect against
contamination and friction while maintaining a clean moist surface.
What is the rationale for using the nursing process in planning care for clients?
As a scientific process to identify nursing diagnoses of a clients' healthcare
problems.
To establish nursing theory that incorporates the biopsychosocial nature of humans.
As a tool to organize thinking and clinical decision making about clients'
healthcare needs.
To promote the management of client care in collaboration with other healthcare
professionals.
Rationale
The nursing process is a problem-solving approach that provides an organized,
systematic, decision making process to effectively address the client's needs and
problems. The nursing process includes an organized framework using
knowledge, judgments, and actions by the nurse as the client's plan of care is
determined, and encompasses assessment, analysis, planning, implementation,
and evaluation of client care.
A nurse is becoming increasingly frustrated by the family members' efforts to
participate in the care of a hospitalized client. What action should the nurse
implement to cope with these feelings of frustration?
, Suggest that other cultural practices be substituted by the family members.
Examine one's own culturally based values, beliefs, attitudes, and practices.
Explain to the family that multiple visitors are exhausting to the client.
Allow the situation to continue until a family member's action may harm the client.
Rationale
Acknowledging a client's beliefs and customs related to sickness and health care
are valuable components in the plan of care that prevents conflict between the
goals of nursing and the client's cultural practices. Cultural sensitivity begins
with examining one's own cultural values to compare, recognize, and
acknowledge cultural bias.
Which technique is most important for the nurse to implement when performing a
physical assessment?
A head-to-toe approach.
The medical systems model.
A consistent, systematic approach.
An approach related to a nursing model.
Rationale
The most important factor in performing a physical assessment is following a
consistent and systematic technique (C) each time an assessment is performed
to minimize variation in sequence which may increase the likelihood of omitting a
step or exam of an isolated area. The method of completing a physical
assessment (A, B, and D) may be at the discretion of the examiner, but a
consistent sequence by the examiner provides a reliable method to ensure
thorough review of the clients' history, complaints, or body systems.
While caring for a child and mother from Cambodia, what action should the nurse
implement to accommodate the clients' cultural needs? initially with the old
Speak est family member to show respect.
Realize that Southeast Asians may not take Western medications.
Ask the husband to step out during the mother's pelvic examination.
Tell the family that planning health care is provided in private with the client.
Rationale
Members of the Asian culture have high respect for others, especially those in
positions of authority. Extended family members need to be included in the
nursing care plan (A). Southeast Asians do not necessarily refuse Western
medications (B). Asians also believe that touching strangers is not acceptable,
particularly health professionals whom they have not previously known, so the
husband should be allowed to remain with his wife during the pelvic exam (C).
Provided that the presence of other family members is not harmful to the client’s
well-being, (D) is not correct.
, Which statement correctly identifies a written learning objective for a client with
peripheral vascular disease?
The nurse will provide client instruction for daily foot care.
The client will demonstrate proper trimming toenail technique.
Upon discharge, the client will list three ways to protect the feet from injury.
After instruction, the nurse will ensure the client understands foot care rationale.
Rationale
An objective should contain four elements: who will perform the activity or
acquire the desired behavior, the actual behavior that the learner will exhibit, the
condition under which the behavior is to be demonstrated, and the specific
criteria to be used to measure success. (C) is a concise statement that is a
learning objective that defines exactly how the client will demonstrate mastery of
the content. (A, B, and D) lack one or more of these elements.
When assessing a client with an indwelling urinary catheter, which observation
requires the most immediate intervention by the nurse?
The drainage tubing is secured over the siderail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame.
Rationale
Maintaining a closed urinary drainage system is important to prevent infection, so
the most immediate priority is to close the clamp (B) to reduce the risk for
ascending microorganisms. If the drainage tubing is secured over the siderail (A),
urine will not be able to flow out of the bladder, so the nurse should next
reposition the tubing. (C and D) indicate correct care of the urinary drainage
system, so documentation of an intact system is the last intervention needed.
The nurse removes the dressing on a client's heel that is covering a pressure
sore one-inch in diameter and finds that there is straw-colored drainage seeping
from the wound. What description of this finding should the nurse include in the
client's record?
Stage 1 pressure sore draining sero-sanguineous drainage.
Pressure sore at bony prominence with exudate noted.
One-inch pressure sore draining serous fluid.
Pressure sore on heel with a small amount of purulent drainage.
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate documentation
based on the information provided. Information to stage this pressure score (A) is
not provided, and sero-sanguineous drainage is pale and watery with a
combination of plasma and red cells, and may be blood-streaked. Exudate (B) is
Return to Overview
Practice Test Assessment Performance
97%Correct
You Rock!
Let's review your results from 3/26/2022 at 6:50 pm MST
Incorrect
Correct
A client who has been on bedrest for several days now has a prescription to
progress activity as tolerated. When the nurse assists the client out of bed for the
first time, the client becomes dizzy. What action should the nurse implement?
Encourage the client to take several slow, deep breaths while ambulating.
Help the client to remain standing by the bedside until the dizziness is relieved.
Instruct the client to remain on bedrest until the healthcare provider is contacted.
Advise the client to sit on the side of the bed for a few minutes before standing
again.
Rationale
The nurse should implement (D), because orthostatic hypotension is a common
result of immobilization, causing the client to feel dizzy when first getting out of
bed following a period of bedrest. To prevent this problem, it is helpful to have the
body acclimate to a standing position by sitting upright for a short period (D)
before rising to a standing position. (A) is unlikely to alleviate the dizziness. (B)
may result in a loss of consciousness. (C) is not indicated and will increase the
potential for complications associated with prolonged immobility.
Which client assessment data is most important for the nurse to consider before
ambulating a postoperative client?
Respiratory rate.
Wound location.
Pedal pulses.
, Pain rating.
Rationale
Mobilization and ambulation increase oxygen use, so it is most important to
assess the client's respiratory rate (A) before ambulation to determine tolerance
for activity. (B, C, and D) are also important, but are of lower priority than (A).
A client is admitted with a stage four pressure ulcer that has a black, hardened
surface and a light-pink wound bed with a malodorous green drainage. Which
dressing is best for the nurse to use first?
Hydrogel.
Exudate absorber.
Wet to moist dressing.
Transparent adhesive film.
Rationale
To provide moisture and loosen the necrotic tissue, the eschar should be covered
first with wet to moist dressings (C), which are discontinued and then a hydrogel
alginate can be placed in the prepared wound bed to prevent further damage of
granulating any surrounding tissue. Although a hydrogel (A) liquefies necrotic
tissue of slough and rehydrates the wound bed, it does not address wicking the
purulent drainage from the wound. Exudate absorbers (B) provide a moist wound
surface, absorb exudate, and support debridement, but do not prepare the wound
bed for proper healing. Transparent dressings (D) are used to protect against
contamination and friction while maintaining a clean moist surface.
What is the rationale for using the nursing process in planning care for clients?
As a scientific process to identify nursing diagnoses of a clients' healthcare
problems.
To establish nursing theory that incorporates the biopsychosocial nature of humans.
As a tool to organize thinking and clinical decision making about clients'
healthcare needs.
To promote the management of client care in collaboration with other healthcare
professionals.
Rationale
The nursing process is a problem-solving approach that provides an organized,
systematic, decision making process to effectively address the client's needs and
problems. The nursing process includes an organized framework using
knowledge, judgments, and actions by the nurse as the client's plan of care is
determined, and encompasses assessment, analysis, planning, implementation,
and evaluation of client care.
A nurse is becoming increasingly frustrated by the family members' efforts to
participate in the care of a hospitalized client. What action should the nurse
implement to cope with these feelings of frustration?
, Suggest that other cultural practices be substituted by the family members.
Examine one's own culturally based values, beliefs, attitudes, and practices.
Explain to the family that multiple visitors are exhausting to the client.
Allow the situation to continue until a family member's action may harm the client.
Rationale
Acknowledging a client's beliefs and customs related to sickness and health care
are valuable components in the plan of care that prevents conflict between the
goals of nursing and the client's cultural practices. Cultural sensitivity begins
with examining one's own cultural values to compare, recognize, and
acknowledge cultural bias.
Which technique is most important for the nurse to implement when performing a
physical assessment?
A head-to-toe approach.
The medical systems model.
A consistent, systematic approach.
An approach related to a nursing model.
Rationale
The most important factor in performing a physical assessment is following a
consistent and systematic technique (C) each time an assessment is performed
to minimize variation in sequence which may increase the likelihood of omitting a
step or exam of an isolated area. The method of completing a physical
assessment (A, B, and D) may be at the discretion of the examiner, but a
consistent sequence by the examiner provides a reliable method to ensure
thorough review of the clients' history, complaints, or body systems.
While caring for a child and mother from Cambodia, what action should the nurse
implement to accommodate the clients' cultural needs? initially with the old
Speak est family member to show respect.
Realize that Southeast Asians may not take Western medications.
Ask the husband to step out during the mother's pelvic examination.
Tell the family that planning health care is provided in private with the client.
Rationale
Members of the Asian culture have high respect for others, especially those in
positions of authority. Extended family members need to be included in the
nursing care plan (A). Southeast Asians do not necessarily refuse Western
medications (B). Asians also believe that touching strangers is not acceptable,
particularly health professionals whom they have not previously known, so the
husband should be allowed to remain with his wife during the pelvic exam (C).
Provided that the presence of other family members is not harmful to the client’s
well-being, (D) is not correct.
, Which statement correctly identifies a written learning objective for a client with
peripheral vascular disease?
The nurse will provide client instruction for daily foot care.
The client will demonstrate proper trimming toenail technique.
Upon discharge, the client will list three ways to protect the feet from injury.
After instruction, the nurse will ensure the client understands foot care rationale.
Rationale
An objective should contain four elements: who will perform the activity or
acquire the desired behavior, the actual behavior that the learner will exhibit, the
condition under which the behavior is to be demonstrated, and the specific
criteria to be used to measure success. (C) is a concise statement that is a
learning objective that defines exactly how the client will demonstrate mastery of
the content. (A, B, and D) lack one or more of these elements.
When assessing a client with an indwelling urinary catheter, which observation
requires the most immediate intervention by the nurse?
The drainage tubing is secured over the siderail.
The clamp on the urinary drainage bag is open.
There are no dependent loops in the drainage tubing.
The urinary drainage bag is attached to the bed frame.
Rationale
Maintaining a closed urinary drainage system is important to prevent infection, so
the most immediate priority is to close the clamp (B) to reduce the risk for
ascending microorganisms. If the drainage tubing is secured over the siderail (A),
urine will not be able to flow out of the bladder, so the nurse should next
reposition the tubing. (C and D) indicate correct care of the urinary drainage
system, so documentation of an intact system is the last intervention needed.
The nurse removes the dressing on a client's heel that is covering a pressure
sore one-inch in diameter and finds that there is straw-colored drainage seeping
from the wound. What description of this finding should the nurse include in the
client's record?
Stage 1 pressure sore draining sero-sanguineous drainage.
Pressure sore at bony prominence with exudate noted.
One-inch pressure sore draining serous fluid.
Pressure sore on heel with a small amount of purulent drainage.
Rationale
Serous drainage is clear watery plasma, so (C) provides accurate documentation
based on the information provided. Information to stage this pressure score (A) is
not provided, and sero-sanguineous drainage is pale and watery with a
combination of plasma and red cells, and may be blood-streaked. Exudate (B) is
