HESI Fundamentals Exam V6 (VERSION 6) (130 Questions with Answers) (2023/2024) (Graded A+)

HESI Fundamentals Exam V6 (VERSION 6) (130 Questions with Answers) (2023/2024) (Graded A+) HESI Fundamentals Exam V6 (VERSION 6) 1. A nurse is teaching a group of older adults about expected changes of aging. Which of the following statements by a group member indicates that the teaching has been effective? "I should expect my heart rate to take longer to return to normal after excessive as I get older." 2. A nurse is caring for a client who is postoperative and has paralytic ileum. Which of the following abdominal assessments should the nurse expect? Absent bowel sounds with distention 3. A nurse is planning care for a client who reports abdominal pain. An assessment by the nurse reveals the client has a temperature of 39.2 degrees C (102 degrees F), heart rate of 105/min, a soft contender abdomen, and census overdue by 2 days. Which of the following findings should be the nurse's priority? Temperature 4. A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following actions should the nurse take? Administe analgesics to the child on a routine schedule throughout the day and night. 5. A nurse is assessing the heart sounds of a client who has developed chest pain that becomes worse wth inspiration. the nurse auscultates a high-pitched scratching sound during both systole and diastole with diaphragm of the stethoscope positioned at the left sternal border. Which of the following heart sounds should the nurse document? Pericardial friction rub 6. A nurse is teaching an assistive personnel (AP) about proper hand hygiene. Which of the following statements by the AP indicates an understanding of the teaching? "There are times I should use soap and water rather than alcohol based hand rub to clean my hands." 7. A nurse is caring for a client who is unstable and has vital signs measured every 15 minutes by an electronic blood pressure machine. The nurse notices the machine begins to measure the blood pressure at varied intervals and the readings are inconsistent. Which of the following actions should the nurse take? Discontinue the machine, and measure the blood pressure manually every 15 min. 8. A nurse is providing teaching to a client who has heart failure about how to reduce his daily intake of sodium. Which of the following factors is the most important in determining the client's ability to learn new dietary habits? The involvement of the client in planning the change 9. A nurse is planning to obtain the vital signs of a 2-year-old child who is experiencing diarrhea and who might have a right ear infection. Which of the following routes should the nurse use to obtain the temperature? Temporal 10. A nurse is witnessing a client sign an informed consent form for surgery. Which of the following describes what the nurse is affirming by this action? The signature on the preoperative consent form is the client's 11. A nurse on a medical-surgical unit is admitting a client. Which of the following information should the nurse document in the client's record first? Assessment 12. A nurse on a medical-surgical unit is washing her hands prior to assisting with surgical procedure. Which of the following actions by the nurse demonstrates proper surgical hand-washing technique? The nurse washes with her hands held higher than her elbows 13. A nurse at a screening clinic is assessing a client who reports a history of a heart murmur related to aortic valve stenosis. At which of the following anatomical areas should the nurse place the stethoscope to auscultate the aortic valve? Second intercostal space to the right of the sternum 14. A nurse is measuring vital signs for a client and notices an irregularity in the pulse. Which of the following actions should the nurse take? Count the apical pulse rate for 1 full minute, and describe the rhythm in the chart 15. A nurse is caring for an older adult client who becomes agitated when the nurse requests that the client's dentures be removed prior to surgery. Which of the following responses should the nurse make? "What worries you about being without your teeth?" 16. A nurse is caring for a client who has a terminal illness. The client asks several questions about the nurse's religious beliefs related to death and dying. Which of the following actions should the nurse take? Encourage the client to express his thoughts about death and dying 17. A nurse is caring for a client who has type 1 diabetes mellitus and is resistant to learning self-injection of insulin. Which of the following statements should the nurse make? "Tell me what I can do to help you overcome your fear of giving yourself injections." 18. A charge nurse is teaching adult cardiopulmonary resuscitation (CPR) to a group of newly licensed nurses. Which of the following actions should the charge nurse teach as the first response in CPR? Confirm unresponsiveness 19. A community health nurse is preparing a campaign about seasonal influenza. Which of the following plans should the nurse include as a secondary prevention? Screening groups of older adults in nursing care facilities for early influenza manifestations 20. A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first? Perform hand hygiene 21. A nurse is obtaining the blood pressure in a client's lower extremity. Which of the following actions should the nurse take? Place the bladder of the cuff over the posterior aspect of the thigh 22. A nurse is caring for a client who requires a chest x-ray. Prior to the client being transported for the procedure, which of the following actions should the nurse take first? Identify the client using two identifiers 23. A nurse in an emergency department is assessing a client who reports diarrhea and decreased urination for 4 days. Which of the following actions should the nurse take to assess the client's skin turgor? Grasp a skin fold on the chest under the clavicle, release it, and note whether it springs back 24. A nurse is providing teaching to an older adult client who has constipation. Which of the following statements should the nurse include in the teaching? "Sit on the toilet 30 minutes after eating a meal." 25. A nurse on a medical-surgical unit is caring for a client. Which of the following actions should the nurse take first when using the nursing process? Obtain client information 26. A nurse on a rehabilitation unit is preparing to transfer a client who is unable to walk from bed to a wheelchair. Which of the following techniques should the nurse use? Place the wheelchair at a 45 degree angle to the bed 27. A nurse is planning weight loss strategies for a group of clients who are obese. Which of the following actions by the nurse will improve the client's commitment to a long-term goal of weight loss? Attempt to increase the client's self-motivation 28. A nurse is caring for an older adult client who is violent and attempting to disconnect her IV lines. The provider prescribes soft wrist restraints. Which of the following actions should the nurse take while the client is in restraints? Remove the restraints one at a time 29. A nurse is caring for a client who is in terminal stage of cancer. Which of the following actions should the nurse take when she observes the client crying? Sit and hold the client's hand 30. A nurse in an oncology clinic is assessing a client who is undergoing treatment for ovarian cancer. Which of the following statements by the client indicates she is experiencing psychological distress? "I keep having nightmares about my upcoming surgery." 31. A nurse is performing an abdominal assessment for an adult client. Identify the correct sequence of steps for this assessment. Inspect, Auscultate, Percuss, Palpate 32. A charge nurse is observing a newly licensed nurse perform tracheostomy care for a client. Which of the following actions by the newly licensed nurse requires intervention? Obtaining cotton balls for the tracheostomy care 33. A nurse is admitting a client who has decreased circulation in his left leg. Which of the following actions should the nurse take first? Evaluate pedal pulses 34. A nurse is preparing a client who is scheduled for hysterectomy for transport to the operating room when the client states she no longer wants to have surgery. Which of the following actions should the nurse take? Notify the provider about the client's decision 35. A nurse is providing preoperative teaching to a client who is scheduled for arthroplasty in the next month that might require a blood transfusion. The client expresses concern about the risk of acquiring an infection from the blood transfusion. Which of the following statements should the nurse make to the client? Donate autologous blood before the surgery 36. A nurse is demonstrating postoperative deep breathing and coughing exercises to a client who will have emergency surgery for appendicitis. Which of the following statements indicates a lack of readiness to learn by the client? The client reports severe pain 37. A nurse observes an assistive personnel (AP) preparing to obtain blood pressure with a regular size cuff for a client who is obese. Which of the following explanations should the nurse give the AP "Using a cuff that is too small will result in an inaccurately high reading." 38. A nurse is inserting an IV catheter for a client that results in a blood spill on her gloved hand. The client has no documented bloodstream infection. Which of the following actions should the nurse take? Carefully remove the gloves and follow with hand hygiene 39. A nurse is receiving a client from the PACU who is postoperative following abdominal surgery. Which of the following actions should the nurse take to transfer the client from stretcher to the bed? Lock the wheels on the bed and stretcher 40. A nurse is preparing to perform mouth care for an unresponsive client. Which of the following actions should the nurse plan to take? Raise the level of the bed 41. A nurse is caring for a client who is incontinent of loose stool and is reporting a painful perineum. Which of the following is the priority nursing action? Check the client's perineum 42. A nurse is caring for a client who is 3 days post-op following a cholecystectomy. The nurse suspects a wound infection because the drainage on the dressing is yellow and thick. The nurse identifies this type of drainage as: Purulent 43. A nurse is collecting a urine specimen for a client to test via urine dipstick the urine's specific gravity. The nurse knows the result will indicate the amount of: Solutes in the urine 44. When obtaining a urine specimen for a culture and sensitivity from an indwelling catheter, the nurse should: Cleanse the entry port priot to withdrawing urine. 45. A client returning from the surgical suite following a vaginal hysterectomy is awake and asking for something to drink. Her post-op diet prescription reads: " clear liquids, advance diet as tolerated." Which of the following is appropriate for the nurse to tell the patient? I am going to listen to your abdomen 46. A nurse is caring for a client who is post-op following a partial colectomy. THe patient has a NG tube set on low continuous suction. The client tells his nurse that his throat is sore and asks the nurse when the NG tube will be taken out. Which of the following responses by the nurse is appropriate at this time? When the GI tract is working again, in about three to five days, the tube can be removed. 47. A client develops a fecal impaction. Before digital removal of the mass, which type of enema should the nurse give to loosen the feces? Oil Retention 48. When a nurse makes an initial assessment of a client who is post-op following gastric resection, the client's NG tube is not draining. The nurse's attempt to irrigate the tube with 10ml 0.9% NaCl was unsuccessful, so she determines that the tube was obstructed. Which of the following actions should the nurse take? Notify the surgeon. 49. A nurse takes an older adult lient who has dysphagia following a CVA to the dining room for dinner. When assisting the client at mealtime, the nurse should: Offer the client tart or sour foods. (This makes it easier for them to swallow) 50. A client is admitted for evaluation and control of HTN. Several hours after the client's admission, the nurse discovers the client supine on the floor, unresponsive to verbal or painful stimuli. The nurse's first reaction at this time is to: Establish an airway 51. A nurse is caring for several clients who are receiving O2 therapy. Which client should the nurse assess most frequently for manifestations of oxygen toxicity? 100% oxygen via partial rebreathing mask 52. A client is hospitalized for an infection of a surgical wound following abd surgery. To promote healing and fight wound infection the nurse plans to arrange to increase the client's intake of: Vitamin C and Zinc 53. When communicating with a client who is hearing impaired, the nurse should Face the client and speak slowly 54. An older adult client has been hospitalized on bed rest for 1 week. The client reports elbow pain. Which of the following is an appropriate initial action for the nurse caring for this client to take Examine the elbow 55. A nurse is caring for a client who has a new prescription for tube feeding. The nurse understands that the provider prescribed tube feeding because the client: Is unable to swallow foods by mouth 56. CPR has been initiated for the client in the ER. The nurse understands that a critical concept related to effective cardiac chest compressions is the need to: Push hard and deep on the chest 57. A nurse is caring for a client who has just had a mastectomy and has a closed wound suction device (hemovac) in place. Which nursing action will ensure proper operation of the device? Collapsing the device whenever its 1/2-2/3 full of air. 58. A client being discharged following abdominal surgery will be performing his own dressing changes at home. It is most important for the nurse to include which of the following in the discharge plan? Demonstration of appropriate hand hygeine 59. The nurse is caring for an adult who has fluid volume excess. When weighing the client, the nurse should Weight the client upon rising. 60. A nurse is planning to collect a liquid stool specimen from a client for ova and parasites. Inaccurate test results may result if the nurse: Refrigerates the collected specimen 61. When replacing a client's surgical dressing, the nurse should: Don clean gloves to remove the old dressing 62. A nurse is preparing to instert a NG tube for a client admitted with bowel obstruction. Which of the following should the nurse do first? Explain the procedure to the client. 63. A nurse is assisting a client with a meal. The client suddenly grabs at her neck with both hands and appears frightened. The appropriate nursing action is to Ask if the patient is choking 64. Which nursing action prevents injury to a client's eye during the administration of eye drops Holding the tip of the container above the conjunctival sac 65. When ambulating a frail, older adult client, the nurse should Use the transfer belt if the client is unsteady 66. A client is recovering fromgallbladder surgery performed under general anesthesia. The nurse should encourage the client to use the incentive spirometer how many times per hour? 4-5 times per hour 67. A client is recovering from an appendectomy for a ruptured appendix has a surgical wound healing by secondary intention. When changing the client's dressing, which observation should the nurse report to the client's surgeon? A halo of erythemia on the surrounding skin 68. While changing the linen on the client's bed, the nurse should Hold the linen away from his body and clothing. 69. A nurse is caring for a client who is receiving an IV that has infiltrated. Which of the following would be an unexpected finding when the nurse assesses the client's infusion line and insertion site? The area around the injection site feels warm when touched. 70. A post-op nurse has an indwelling catheter in place to gravity drainage. The nurse notes that the client's urine bag has been empty for 2 hours. The first action the nurse shoudl take is to: Check to see if the tubing was kinked. 71. A client's provider has ordered that sputum specimen be collected for culture and sensitivity. The nurse plans to collect this specimen... In the morning upon rising. 72. The mother of a toddler calls the nurse "Help! My baby is choking on his food!" The nurse determines that the heimlich maneuver is necessary based on which finding: Inability of the toddler to cry or speak 73. A client returns from surgery with two penrose drains in place. Anticipating frequent dressing changes, what should the nurse use around the incision site? Montgomery straps 74. A client who is post-op following laparotomy is reporting pain and dry mouth. The client has morphine sulfate ordered to control the pain. Before administrering the morphine sulfate prescribed for the client the nurse should first Measure the client's vital signs. 75. A nurse is teaching a lient with a new colostomy about how to irrigate the ostomy. The nurse realizes that the client needs further teaching when the client Positions the irrigating solution bag 30 inchees above the stoma 76. A nurse is performing an eye irrigation for the client who has been exposed to smoke and ash. Which of the following nursing actions should receive the highest priority during the irrigation? Wearing gloves during the procedure. 77. In planning care for a client with surgical wound helating by secondary intention, the nurse can anticipate that the client will Be at an increased susceptibility for infection. 78. A nurse is assessing a client admitted with sudden onset of severe back pain of unknow origin. Which statement would be most effective for the nurse to use to elicit further information from this client about his pain? Tell me how you are feeling right now. 79. A nurse has inserted an indwelling catheter for a male patient. Where should the nurse tape the catheter to prevent pressure on the client's urethra at the penoscrotal junction? Lower abdomen 80. A nurse is in a public building when someone cries out "Help! I think he is having a heart attack!" The nurse responds to the scene and finds the unconcious adult lying on the floor. Another bystander has obtained an AED. The nurse's first action, after making certain someone has called for EMS, should be to Administer cardiac compressions. 81. A nurse is using the I-SBAR communication tool to provide the client's provider with information about the client. The nurse should convey the client's pain status in which portion of the report? Assessment 82. A nurse is providing discharge teaching to a client who is recovering from lung cancer. The provider instructed the client that he could resume lower-intensity activities of daily living. Which of the following activities should the nurse recommend to the client? Washing dishes 83. A nurse in the emergency department is caring for a client who has abdominal trauma. Which of the following assessment findings should the nurse identify as an indication of hypovolemic shock? Tachycardia 84. A nurse is planning to assess the abdomen of a client who reports feeling bloated for several weeks. Which of the following methods of assessment should the nurse use first? Inspection 85. A nurse is responding to a parent's question about his infant's expected physical development during the first year of life. Which of the following information should the nurse include? A 10-month-old infant can pull up to a standing position. 86. A client who reports shortness of breath requests her nurse's help in changing positions. After repositioning the client, which of the following actions should the nurse take next? Observe the rate, depth, and character of the client's respirations. 87. A nurse is planning to insert a nasogastric tube for a client after explaining the procedure. The client states, "You are not putting that hose down my throat." Which of the following statements should the nurse make? "I can see that this is upsetting you." 88. An assistive personnel (AP) is assisting a nurse with the care of a female client who has an indwelling urinary catheter. Which of the following actions by the AP indicates a need for further teaching? The AP hangs the collection bag at the level of the bladder. 89. A nurse is explaining the use of written consent forms to a newly-licensed nurse. The nurse should ensure that a written consent form has been signed by which of the following clients? A client who has a prescription for a transfusion of packed red blood cells. 90. A nurse is planning care for a client who is postoperative and has a history of poor nutritional intake. Which of the following actions should the nurse include in the plan of care to promote wound healing? Provide a protein intake of 1.5 g/kg of body weight per day. 91. A nurse is caring for a client who has a prescription for a vest restraint. Which of the following actions should the nurse take? Tie the restraint with a quick-release knot. 92. A nurse is performing a neurological assessment for a client. Which of the following examinations should the nurse use to check the client's balance? Romberg test 93. A nurse is caring for a client who has a fecal impaction. Before digital removal of the mass, which of the following types of enemas should the nurse plan to administer to soften the feces? Oil retention 94. A nurse is caring for a client who has acute renal failure. Which of the following assessments provides the most accurate measure of the client's fluid status? Daily weight 95. A nurse is caring for a client who is 48 hr postoperative following a small bowel resection. The client reports gas pains in the periumbilical area. The nurse should plan care based on which of the following factors contributing to this postoperative complication? Impaired peristalsis of the intestines 96. A nurse is teaching a client who is postoperative how to use a flow-oriented incentive spirometer. Which of the following instructions should the nurse include? Cough deeply after each use. 97. A nurse is teaching a client who has lower extremity weakness how to use a four-point crutch gait. Which of the following instructions should the nurse include in the teaching? "Bear weight on both of your legs." 98. A nurse is called away for an emergency while conversing with a client who is concerned about his medical diagnosis. The nurse returns to the client promptly, as promised. Which of the following ethical principles is the nurse demonstrating? Fidelity 99. A nurse is reviewing the correct use of a fire extinguisher with a client. Which of the following actions should the nurse direct the client to take first? Remove the safety pin from the extinguisher. 100. A nurse is caring for a client who is receiving a blood transfusion. The client reports flank pain and the nurse notes reddish-brown urine in the client's urinary catheter bag. The nurse recognizes these manifestations as which of the following types of transfusion reactions? Hemolytic 101. A newly licensed nurse is preparing to administer medications to a client. The nurse notes that the provider has prescribed a medication that is unfamiliar to her. Which of the following actions should the nurse take? Consult the medication reference book available on the unit. 102. A nurse is caring for a client who is postoperative following abdominal surgery. Which of the following actions should the nurse take first after discovering that the client's wound has eviscerated? Cover the incision with a moist sterile dressing. 103. A nurse is preparing to administer a cleansing enema to a client. Which of the following actions should the nurse plan to take? Position the client on his left side. 104. A nurse in a long-term care facility is admitting a client who is incontinent and smells strongly of urine. His partner, who has been caring for him at home, is embarrassed and apologizes for the smell. Which of the following responses should the nurse make? "It must be difficult to care for someone who is confined to bed." 105. A nurse is preparing to provide chest physiotherapy for a client who has left lower lobe atelectasis. Which of the following actions should the nurse plan to take? Place the client in Trendelenburg's position. 106. A nurse is caring for a client who is receiving IV therapy via a peripheral catheter. The nurse should identify that which of the following findings is an indication of infiltration? Edema at the infusion site 107. A nurse is caring for a client who, while sitting in a chair, starts to experience a seizure. Which of the following actions should the nurse take? Lower the client the floor and place a pad under the client's head. 108. A nurse is preparing to administer an intramuscular injection to a young adult client. Which of the following injection sites is the safest for this client? Ventrogluteal 109. A nurse is caring for a client who has bilateral casts on her hands. Which of the following actions should the nurse take when assisting the client with feeding? Sit at the bedside while feeding the client. 110. A nurse on a mental health unit is preparing to terminate the nurse-client relationship with a client who no longer requires care. Which of the following concepts should the nurse and client discuss in the termination phase of the relationship? Loss 111. A nurse is providing education about cultural and religious traditions and rituals related to death for the assistive personnel on the unit. Which of the following information should the nurse include? People who practice Judaism status with the body of the deceased until burial. 112. A nurse in a provider's office is collecting information from an older adult who reports that he has been taking acetaminophen 500 mg/day for severe joint pain. The nurse should instruct the client that large doses of acetaminophen could cause which of the following adverse effects? Liver damage 113. A nurse is caring for a client who has a terminal illness. Which of the following findings indicates that the client's death is imminent? Cold extremities 114. A nurse is planning to document care provided for a client. Which of the following abbreviations should the nurse use? PC for after meals 115. A nurse is reviewing the laboratory values for a client who has a positive Chvostek's sign. Which of the following laboratory findings should the nurse expect? Decreased calcium 116. A nurse in a provider's office is reviewing the laboratory findings of a client who reports chills and aching joints. The nurse should identify which of the following findings as an indication that the client has an infection? WBC 15,000 mm3 117. A nurse on a surgical unit is receiving a client who had abdominal surgery from the postanesthesia care unit. Which of the following assessments should the nurse make first? Airway 118. A nurse is planning to perform passive range-of-motion exercises for a client. Which of the following actions should the nurse take? Repeat each joint motion five times during each session. 119. A nurse is caring for a client who has Clostridium difficile and is in contact isolation. Which of the following actions should the nurse take? Wear gloves when changing the client's gown 120. A home health nurse is planning to provide health promotion activities for a group of clients in the community. Which of the following activities is an example of the nurse promoting primary prevention? Educating clients about the recommended immunization schedule for adults 121. A nurse is teaching a client how to self-administer insulin. Which of the following actions should the nurse take to evaluate the client's understanding of the process within the psychomotor domain of learning? Have the client demonstrate the procedure. 122. A client is being discharged home with oxygen therapy via a nasal cannula. Which of the following instructions should the nurse provide to the client and family? Wear cotton clothing to avoid static electricity. 123. A nurse in a provider's office is assessing a client who has heart failure. The client has gained weight since her last visit and her ankles are edematous. Which of the following findings by the nurse is another clinical manifestation of fluid volume excess? Bounding pulse 124. A nurse on a telemetry unit is caring for a client who had a myocardial infarction. The client states "All this equipment is making me nervous." Which of the following responses should the nurse make? "All of this equipment can be frightening." 125. A nurse is providing oral care for a client who is unconscious. Which of the following actions should the nurse take? Place the client in a lateral position with the head turned to the side before beginning the procedure. 126. An adolescent client in an outpatient mental health facility tells the nurse that it is hard to follow his treatment plans because his friends discourage him. Which of the following statements should the nurse make? "Tell me more about how your friends discourage you." 127. A nurse is applying an ice bag to the ankle of a client following a sports injury. Which of the following actions should the nurse take? Fill the bag two-thirds full with ice. 128. A nurse is reviewing measures to prevent back injuries with assistive personnel (AP). Which of the following instructions should the nurse include? When lifting an object, spread your feet apart to provide a wide base of support. 129. A nurse is providing teaching about food choices to a client who has a prescription for a clear liquid diet. Which of the following selections by the client indicates an understanding of the teaching? Gelatin 130. A nurse is planning care for a client who has a single-lumen nasogastric (NG) tube for gastric decompression. Which of the following actions should the nurse include in the plan of care? (Select all that apply) 1. Provide oral hygiene frequently 2. Measure the drainage from the NG tube every shift 3. Secure the NG tube to the client's gown