NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?
Immediately stop the infusion.
Lower the height of the enema
bag.
Advance the enema tubing 2 to 3 inches.
Clamp the tube for 2 minutes, then restart the infusion.
Abdominal cramping during a soapsuds enema may be due to too rapid administration
of the enema solution. Lowering the height of the enema bag slows the flow and allows
the bowel time to adapt to the distention without causing excessive discomfort.
Stopping the infusion is not necessary.
Advancing the enema tubing is not appropriate. Clamping the tube for several minutes
then restarting the infusion may be attempted if slowing the infusion does not relieve
the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a
nurse observes that the client's skin is dry and scaly. The nurse applies emollients and
reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
The nurse also should have instituted a plan to increase activity.
The nurse provided supportive nursing care for the well-being of the client.
Debridement of the pressure ulcer should have been done before the dressing was
applied Treatment should not have been instituted until the health care provider's
prescriptions were received.
According to the Nurse Practice Act, a nurse may independently treat human responses
to actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing was
applied. Application of an emollient and reinforcing a dressing are independent nursing
functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a
fight and that the client is now lying unconscious on the floor. What is the most important
action the nurse needs to take?
Ask the client if he is
okay. Call security from
the room.
Find out if there is anyone else in the
room. Ask security to make sure the
room is safe
1
,NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if
the client is okay and make sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
4 to 8 hours
12 to 24 hours
24 to 48
hours 72 to
96 hours
Best practice guidelines recommend replacing administration sets no more frequently
than 72 to 96
hours after initiation of use in patients not receiving blood, blood products, or fat
emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
A nurse is taking care of a client who has severe back pain as a result of a work injury. What
nursing considerations should be made when determining the client's plan of care? Select
all that apply.
Ask the client what is the client's acceptable level
of pain. Eliminate all activities that precipitate the
pain.
Administer the pain medications regularly around the clock.
Use a different pain scale each time to promote patient
education. Assess the client's pain every 15 minutes
The nurse works together with the client in order to determine the tolerable level of
pain. Considering that the client has chronic, not acute pain, the goal of the pain
management is to decrease pain to the tolerable level instead of eliminating pain
completely. Administration of pain medications around the clock will provide the stable
level of pain medication in the blood and relieve the pain. Elimination of all activities
that precipitate the client's pain is not possible even though the nurse will try to
minimize such activities.
The same pain scale should be used for assessment of the client's pain level helps to
ensure consistency and accuracy in the pain assessment. Only management of acute
pain such as postoperative pain requires the pain assessment at frequent intervals.
The nurse is preparing to administer eardrops to a client that has impacted cerumen.
Before administering the drops, the nurse will assess the client for which
contraindications? Select all that apply.
2
,NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
Allergy to the medication
Itching in the ear canal
Drainage from the ear
canal Tympanic
membrane rupture
Partial hearing loss in the affected ear
Contraindications to eardrops include allergy to the medication, drainage from the ear
canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted
cerumen and is not a contraindication to the use of eardrops. Itching may occur with
some ear conditions and is not a contraindication to the use of eardrops.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select
all that apply.
Tetany
Seizures
Diarrhea
Weakness
Dysrhythmi
as
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are
associated with
low calcium or sodium levels. Because of potassium's role in the
sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and
cardiac dysrhythmias.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction
should the nurse give the client about this medication?
Prolonged use can cause dark concentrated urine.
The medication is best absorbed when taken on an empty
stomach. Take the medication with aluminum hydroxide to
minimize GI upset. Drinking alcohol daily can cause drug-
induced hepatitis
Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause
dark concentrated urine. The client should take isoniazid with meals to decrease GI
upset. Clients should avoid taking aluminum antacids at the same time as this
medication because it impairs absorption.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does
the nurse expect the dietary plan to include?
3
, NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
Low in fat
High in iron
High in
fluids Low in
residue
A common side effect of vincristine is a paralytic ileus that results in constipation.
Preventative measures include high-fiber foods and fluids that exceed minimum
requirements. These will keep the stool bulky and soft, thereby promoting evacuation.
Low in fat, high in iron, and low in residue dietary plans will not provide the roughage
and fluids needed to minimize the constipation associated with vincristine.
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room,
sings all night and keeps me awake." The neighboring client has dementia and is awaiting
transfer to a nursing home. How can the nurse best handle this situation?
Tell the neighboring client to stop
singing. Close the doors to both clients'
rooms at night.
Give the complaining client the prescribed as needed
sedative. Move the neighboring client to a room at the
end of the hall
Moving the client who is singing away from the other clients diminishes the disturbance.
A client with dementia will not remember instructions. It is unsafe to close the doors of
clients' rooms because they need to be monitored. The use of a sedative should not be
the initial intervention
The nurse is providing postoperative care to a client who had a submucosal resection (SMR)
for a deviated septum. The nurse should monitor for what complication associated with this
type of surgery?
Occipital headache
Periorbital crepitus
Expectoration of
blood Changes in
vocalization
After an SMR, hemorrhage from the area should be suspected if the client is swallowing
frequently or expelling blood with saliva. A headache in the back of the head is not a
complication of a submucosal resection. Crepitus is caused by leakage of air into tissue
spaces; it is not an expected complication of SMR. The nerves and structures involved
with speech are not within the operative area. However, the sound of the voice is
altered temporarily by the presence of nasal packing and edema.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result
4
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?
Immediately stop the infusion.
Lower the height of the enema
bag.
Advance the enema tubing 2 to 3 inches.
Clamp the tube for 2 minutes, then restart the infusion.
Abdominal cramping during a soapsuds enema may be due to too rapid administration
of the enema solution. Lowering the height of the enema bag slows the flow and allows
the bowel time to adapt to the distention without causing excessive discomfort.
Stopping the infusion is not necessary.
Advancing the enema tubing is not appropriate. Clamping the tube for several minutes
then restarting the infusion may be attempted if slowing the infusion does not relieve
the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a
nurse observes that the client's skin is dry and scaly. The nurse applies emollients and
reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
The nurse also should have instituted a plan to increase activity.
The nurse provided supportive nursing care for the well-being of the client.
Debridement of the pressure ulcer should have been done before the dressing was
applied Treatment should not have been instituted until the health care provider's
prescriptions were received.
According to the Nurse Practice Act, a nurse may independently treat human responses
to actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing was
applied. Application of an emollient and reinforcing a dressing are independent nursing
functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had a
fight and that the client is now lying unconscious on the floor. What is the most important
action the nurse needs to take?
Ask the client if he is
okay. Call security from
the room.
Find out if there is anyone else in the
room. Ask security to make sure the
room is safe
1
,NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if
the client is okay and make sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
4 to 8 hours
12 to 24 hours
24 to 48
hours 72 to
96 hours
Best practice guidelines recommend replacing administration sets no more frequently
than 72 to 96
hours after initiation of use in patients not receiving blood, blood products, or fat
emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
A nurse is taking care of a client who has severe back pain as a result of a work injury. What
nursing considerations should be made when determining the client's plan of care? Select
all that apply.
Ask the client what is the client's acceptable level
of pain. Eliminate all activities that precipitate the
pain.
Administer the pain medications regularly around the clock.
Use a different pain scale each time to promote patient
education. Assess the client's pain every 15 minutes
The nurse works together with the client in order to determine the tolerable level of
pain. Considering that the client has chronic, not acute pain, the goal of the pain
management is to decrease pain to the tolerable level instead of eliminating pain
completely. Administration of pain medications around the clock will provide the stable
level of pain medication in the blood and relieve the pain. Elimination of all activities
that precipitate the client's pain is not possible even though the nurse will try to
minimize such activities.
The same pain scale should be used for assessment of the client's pain level helps to
ensure consistency and accuracy in the pain assessment. Only management of acute
pain such as postoperative pain requires the pain assessment at frequent intervals.
The nurse is preparing to administer eardrops to a client that has impacted cerumen.
Before administering the drops, the nurse will assess the client for which
contraindications? Select all that apply.
2
,NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
Allergy to the medication
Itching in the ear canal
Drainage from the ear
canal Tympanic
membrane rupture
Partial hearing loss in the affected ear
Contraindications to eardrops include allergy to the medication, drainage from the ear
canal, and tympanic membrane rupture. Partial hearing loss may occur with impacted
cerumen and is not a contraindication to the use of eardrops. Itching may occur with
some ear conditions and is not a contraindication to the use of eardrops.
What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select
all that apply.
Tetany
Seizures
Diarrhea
Weakness
Dysrhythmi
as
Tetany is caused by hypocalcemia. Seizures caused by electrolyte imbalances are
associated with
low calcium or sodium levels. Because of potassium's role in the
sodium/potassium pump, hyperkalemia will cause diarrhea, weakness, and
cardiac dysrhythmias.
A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction
should the nurse give the client about this medication?
Prolonged use can cause dark concentrated urine.
The medication is best absorbed when taken on an empty
stomach. Take the medication with aluminum hydroxide to
minimize GI upset. Drinking alcohol daily can cause drug-
induced hepatitis
Daily alcohol intake can cause drug induced hepatitis. Prolonged use does not cause
dark concentrated urine. The client should take isoniazid with meals to decrease GI
upset. Clients should avoid taking aluminum antacids at the same time as this
medication because it impairs absorption.
To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does
the nurse expect the dietary plan to include?
3
, NURS HESI FUNDA EXAM QUESTIONS WITH 100%
VERIFIED ANSWERS 2022/2023 UPDATE GRADED A+
Low in fat
High in iron
High in
fluids Low in
residue
A common side effect of vincristine is a paralytic ileus that results in constipation.
Preventative measures include high-fiber foods and fluids that exceed minimum
requirements. These will keep the stool bulky and soft, thereby promoting evacuation.
Low in fat, high in iron, and low in residue dietary plans will not provide the roughage
and fluids needed to minimize the constipation associated with vincristine.
A postoperative client says to the nurse, "My neighbor, I mean the person in the next room,
sings all night and keeps me awake." The neighboring client has dementia and is awaiting
transfer to a nursing home. How can the nurse best handle this situation?
Tell the neighboring client to stop
singing. Close the doors to both clients'
rooms at night.
Give the complaining client the prescribed as needed
sedative. Move the neighboring client to a room at the
end of the hall
Moving the client who is singing away from the other clients diminishes the disturbance.
A client with dementia will not remember instructions. It is unsafe to close the doors of
clients' rooms because they need to be monitored. The use of a sedative should not be
the initial intervention
The nurse is providing postoperative care to a client who had a submucosal resection (SMR)
for a deviated septum. The nurse should monitor for what complication associated with this
type of surgery?
Occipital headache
Periorbital crepitus
Expectoration of
blood Changes in
vocalization
After an SMR, hemorrhage from the area should be suspected if the client is swallowing
frequently or expelling blood with saliva. A headache in the back of the head is not a
complication of a submucosal resection. Crepitus is caused by leakage of air into tissue
spaces; it is not an expected complication of SMR. The nerves and structures involved
with speech are not within the operative area. However, the sound of the voice is
altered temporarily by the presence of nasal packing and edema.
A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result
4
