HESI FUNDAMENTALS EXIT EXAM VERSION 1. QUESTIONS AND ANSWERS WITH RATIONALES.

51. The nurse is conducting an initial admission assessment for a woman who is Mexican- American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the nurse include in the assessment? a. Provider an interpreter to convey the meaning of words and messages in translation b. Commend the client for her patience after a long wait in the admission process c. Arrange for the hospital chaplain to visit the client during her hospital stay d. Rely on cultural norms as the basis for providing nursing care for this client 52. During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this statement? a. Provide information about the hours and location of the chapel b. Document the statement of the client’s spiritual assessment c. Invite the client to a healing service for people of all religions d. Offer to contact a spiritual advisor of the client’s choice 53. The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement? A. Notify the OR staff of the client’s confusion B. Have the client sign a new surgical consent C. Add the additional information to the consent D. Inform the surgeon about the client’s concern 54. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. A. Administer nasal oxygen at a rate of 5 L/min B. Help the client to lie back down in the bed C. Quickly pivot the client to the chair and elevate the legs D. Check the client’s blood pressure and pulse deficit 55. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first? a. Divert the client’s attention b. Call for additional help from staff c. Document the planned action d. Re-assess the client situation