HESI Fundamentals Exam

HESI Fundamentals Exam a 35 year old female client with cancer refuses to allow the nurse to insert an IV for a scheduled chemotherapy treatment, and states that she is ready to go home and die. What intervention should the nurse initiate? A. evaluate the client's mental status for competence to refuse treatment B. review the client's medical record for an advance directive C. determine if a DNR prescription has been obtained D. document that the client is being discharged against medical advice Ans- A. evaluate the client's mental status for competence to refuse treatment A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure. Which laboratory test indicated the client's protein status for the longest length of time. A. Urine urea B. transferrin C. prealbumin D. serum albumin Ans- D. serum albumin What client statement indicates to the nurse that the client requires assistance with bathing? A. "I only bathe every other day" B. "I left my eyeglasses at home" C. "I don't understand why I'm so weak and tired" D. "I wasn't able to pack a bag before I left for the hospital" Ans- C. "I don't understand why I'm so weak and tired" How should a nurse handle linens that are soiled with incontinent feces? A. Place the soiled linens in a pillow case and deposit them in the dirty linen hamper B. put the soiled linens in an isolation bag, then place it in the dirty linen hamper C. Ask the housekeeping staff to pick up the soiled linen from the dirty utility room D. place an isolation hamper in the client's room and discard the linens in it Ans- D. place an isolation hamper in the client's room and discard the linens in it When caring for an immobile client, what nursing diagnosis has the highest priority? A. altered tissue perfusion B. impaired gas exchange C. risk for fluid volume deficit D. risk for impaired skin integrity Ans- B. impaired gas exchange The nurse assess an immobile, elderly male client and determines that his blood pressure is 138/60, his temperature is 95.8F, and his output is 100 mL of concentrated urine during the last hour. He has wetsounding lung sounds, and increased respiratory secretions. Based on these assessment findings, what nursing action is the most important for the nurse to implement? A. encourage additional additional fluid intake B. provide the client with an additional blanket C. turn the patient Q2 D. administer a PRN anti hypertensive prescription Ans- C. turn the patient Q2 The home health nurse visits an elderly female client who had a brain attack three months ago and is now able to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications for this client's case? A. The client's pulse rate is 10 beats higher than it was at the last visit one week ago B. the client tells the nurse that she does not have much of an appetite today C. the husband, who is the caregiver, begins to weep when you ask how he is doing D. the nurse notes that there are numerous scatter rubs throughout the house Ans- D. the nurse notes that there are numerous scatter rubs throughout the house 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? A. stage 1 pressure sore draining sero-anguineous drainage B. one-inch pressure sore draining serous fluid C. pressure sore draining serous fluid D. pressure sore on heel with a small amount of purulent drainage Ans- B. one-inch pressure sore draining serous fluid A medication is prescribed to be given QID. What schedule should the nurse use to administer this prescription? A. 800 B. 0800, 1200, 1600, 2000 C. every other day at 0800 D. 0800, 1200, 1600, 2000, 0000, 0400 Ans- B. 0800, 1200, 1600, 2000 The nurse working in the emergency department is assessing four client's ability to tolerate pain. Which client is likely to tolerate a higher level of pain. A. A 23-year-old woman who sprained her knee while biking B. a 55-year-old woman who has had moderate low back pain for three months C. A 10-year-old who was burned by a camp fire earlier today D. A 70 year-old who has a postoperative infection from a surgery one week ago Ans- B. a 55-year-old woman who has had moderate low back pain for three months A 4-year old boy who is scheduled for a tonsillectomy and adenoidectomy asks the nurse, " will it hurt to have my tonsils and adenoids taken out?" Which response is best for the nurse to provide? a. "It won't hurt because you're such a big boy" b. "It may hurt a little because of the incision made in your throat" c. "It won't hurt because we put you to sleep" d. "It may hurt but we'll give you medicine to help you feel better" Ans- d. "It may hurt but we'll give you medicine to help you feel better" A low-sodium, low-protein diet is prescribed for a 45-year-old client with renal insufficiency and hypertension, who gained 3 pounds in the last month. The nurse determines that the client has been non compliant with the diet, based on which report from the 24-hour dietary recall? (select all that apply) A. bedtime snack of crackers and milk B. breakfast of eggs, bacon, toast, and coffee C. lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee D. dinner of vegetable lasagna, tossed salad, sherbet, and iced tea E. snack of potato chips, and diet soda Ans- A, B, C & E What intervention should the nurse include in the plan of care for a client who is being treated with an Unna's paste boot for leg ulcers due to a chronic venous insufficiency? A. check capillary refill of toes on lower extremity with Unna's paste boot B. apply dressing to a wound area before applying the Unna's paste boot C. remove the Unna's paste boot Q8H to assess wound healing D. wrap the leg from the knee down towards to foot Ans- A. check capillary refill of toes on lower extremity with Unna's paste boot A male client has a nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for the client. A. Reassurance the client that his faith will be regained with time and support B. consult with the staff chaplain and ask that the chaplain visit with the client C. use reflective listening techniques when the client expresses spiritual doubts D. use distraction techniques during times of spiritual stress and crisis Ans- C. use reflective listening techniques when the client expresses spiritual doubts A client has a nursing diagnosis of "Spiritual distress related to loss of hope, secondary to impending death." What intervention is best for the nurse to implement when caring for this client? A. instruct the client's family to focus on positive aspect of the client's life B. assist and support the client in establishing short-term goals C. encourage the client to make future plans, even if they are unrealistic D. help the client to accept the final stage of life Ans- B. assist and support the client in establishing short-term goals A female nurse who sometimes tries to save time by putting medications in her uniform to clients, confides that after arriving home she found hydrocodone (Vicodin) tablet in her pocket. Which possible outcome of this situation should be the nurse's greatest concern? a. accused of unprofessional conduct b. accused of diversion c. reported for stealing d. reported for a HIPAA violation Ans- b. accused of diversion A signed consent form indicated a client should have an EKG, but a myelogram was performed instead. Though the myelogram revealed the cause of the client's back pain, which was subsequently treated, the client filed a lawsuit against the nurse and healthcare provider for performing the incorrect procedure. The court is likely to rule in favor of the plantiff because these events represent which infraction? A. An unintentional tort because the client benefited from having the myelogram B. Assault and battery with deliberate intent to deviate from the consent form C. A quisi-intentional because a similar mistake can happen to anyone D. failure to respect client autonomy to choose based on international tort law Ans- B. Assault and battery with deliberate intent to deviate from the consent form A 75 year old client who has a history of end stage renal failure and advanced lung cancer, recently had a stroke. Two days ago the healthcare provider discontinued the client's dialysis treatments, starting the death is inevitable, but the client is discontinues and will not sign a DNR directive. A. review the client's most recent laboratory reports B. determine who is legally empowered to make decisions