HESI Fundamentals Version 1 |Best Rated Questions and Answers| Latest 2022/2023

HESI Fundamentals Version 1 |Best Rated Questions and Answers 1. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states “clean the wound and then apply collagenase. ” collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the nurse cleanse the pressure ulcer? A. Lightly coat the wound with povidone-iodine solution B. Irrigate the wound with sterile normal saline C. Flush the wound with sterile hydrogen peroxide D. Remove the eschar with a wet-to-dry dressing 2. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement? A. Document the client’s circadian rhythms B. Assess for flushed, warm skin regularly C. Measure temperature at regular intervals D. Vary sites for temperature measurement 3. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? A. Position the client supine for a few minutes B. Assist the client to stand at the bedside C. Apply the blood pressure cuff securely D. Record the client’s pulse rate and rhythm 4. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they are with client. When the family leaves, what action should the nurse take first? A. Apply the restraints to maintain the client’s safety. B. Reassess the client to determine the need for continuing restraints. C. Document the time the family left and continue to monitor the client. D. Call the healthcare provider for a new prescription. 5. A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider? A. Potassium 3. 1mEq/L (3. 1 mmil/L) B. Sodium 142 mEq/L (142 mmol/L) C. Total calcium 9. 2 mg/dl (2. 3 mmol/L) D. Chloride 98 mEq/L (98 mmil/L) 6. The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet? A. Between the toes. B. Around the ankles. C. On dorsal surfaces D. Over the heels. 7. A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the unlicensed assistive personnel (UAP) who is preparing to assist this client with a bed bath? A. Take measures to promote as much comfort as possible. B. Report any signs of drug addiction to the nurse immediately. C. Wait until the client's pain is gone before assisting with personal care. D. This client's pain will be difficult to manage, since the cause is unknown. 8. An older client who is able to stand but not to ambulate receives a prescription to be mobilized into a chair as tolerated during each day. What is the best action for the nurse to implement when assisting the client from the bed to the chair? A. Use a mechanical lift to transfer from the bed to a chair. B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair. C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three. D. Place a transfer belt around the client, assist to stand, and pivot to a chair that is placed at a right angle to the bed. 9. A male client has a nursing diagnosis of "spiritual distress. " What intervention is best for the nurse to implement when caring for this client? A. Use distraction techniques during times of spiritual stress and crisis. B. Reassure the client that his faith will be regained with time and support. C. Consult with the staff chaplain and ask that the chaplain visit with the client. D. Use reflective listening techniques when the client expresses spiritual doubts. 10. The nurse obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the nurse implement first? A. Use an electronic sphygmomanometer to take the BP every 30 minutes.