HESI FUNDAMENTALS EXAM WITH 100% CORRECT
ANSWERS WITH RATIONALES 2023 COMPLETE A+ GUIDE.
• Which client assessment data is most important for the nurse to consider
beforeambulating a postoperative client?
• Respiratory rate.
• Wound location.
• Pedal pulses.
• Pain rating.
Rationale: Mobilization and ambulation increase oxygen use, so it is most
importantto assess the client's respiratory rate before ambulation to determine
tolerance for activity.
• A signed consent form indicated a client should have an electromyogram, 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
likelyto rule in favor of the plaintiff because these events represent which infraction?
• A quasi-intentional tort because a similar mistake can happen to anyone.
• Failure to respect client autonomy to choose based on intentional tort law.
• Assault and battery with deliberate intent to deviate from the consent form.
• An unintentional tort because the client benefited from having the
myelogram. Rationale: The client was not properly informed of the procedure,
and failure to obtain informed consent constitutes assault and battery.
• A medication is prescribed to be given QID. Which schedule should the nurse use
to administer this prescription?
a. 0800, 1200, 1600, 2000.
b. 0800.
c. Every other day at 0800.
d. 0800, 1200, 1600, 2000, 0000, 0400.
Rationale: QID means four times per day.
• The nurse formulates the nursing problem of, "Ineffective health maintenance related
to lack of motivation" for a client with Type 2 diabetes. Which finding supports this
nursingproblem?
• Does not check capillary blood glucose as directed.
• Occasionally forgets to take daily prescribed medication.
• Cannot identify signs or symptoms of high and low blood glucose.
• Eats anything and does not think diet makes a difference in health.
Rationale: The nursing problem of ineffective health maintenance refers to
an inability to identify, manage, and/or seek out help to maintain health, and
is best
exemplified in the client's belief or understanding about diet and health maintenance.
• In providing care for a terminally ill resident of a long-term care facility, the
nurse determines that the resident is exhibiting signs of impending death and has
, a do notresuscitate or DNR status. Which intervention should the nurse
implement first?
• Request hospice care for the client.
• Report the client's acuity level to the nursing supervisor.
• Notify family members of the client's condition.
• Inform the chaplain that the client's death is imminent.
Rationale: The nurse's first priority is to notify the family of the resident's
impendingdeath.
• 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 noncompliant with the diet, based on which
report from the 24-hour dietary recall? (Select all that apply.)
• Snack of potato chips and diet soda.
• Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
• Breakfast of eggs, bacon, toast, and coffee.
• Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
• Bedtime snack of crackers and milk.
Rationale: Potato chips are high in sodium. Tuna is high in protein. Bacon and
crackers are high in sodium.
• A client is admitted with a stage four pressure injury that has a black, hardened
surface(eschar) that is stable. Which dressing is best for the nurse to use first?
• Hydrogel.
• Exudate absorber.
• No dressing.
• Transparent adhesive film.
Rationale: If eschar is dry and intact and debridement is not part of the plan of
care, no dressing is used, allowing eschar to act as physiological cover.
• Which statement correctly identifies a written learning objective for a client
withperipheral vascular disease?
• The nurse will provide client instruction for daily foot care.
• The client will demonstrate proper trimming toenail technique.
• Upon discharge, the client will list three ways to protect the feet from injury.
• After instruction, the nurse will ensure the client understands the foot
carerationale.
Rationale: An objective should contain four elements: who will perform the
activity or acquire the desired behavior, the actual behavior that the learner will
exhibit, the condition under which the behavior is to be demonstrated, and the
specific criteria to be used to measure success. "Upon discharge, the client will list
three ways to protectthe feet from injury" is a concise statement that is a learning
objective that defines exactly how the client will demonstrate mastery of the
content.
, • The nurse determines a client's IV solution is infusing at 250 mL/hr. The prescribed
rateis 125 mL/hr. Which action should the nurse take first?
• Determine when the IV solution was started.
• Slow the IV infusion to keep vein open rate.
• Assess the IV insertion site for swelling.
• Report the finding to the healthcare provider.
Rationale: The nurse should first slow the IV flow rate to keep vein open (KVO)
rateto prevent further risk of fluid volume overload, then gather additional
assessment data, such as when the IV solution was started and the appearance of the
IV insertion site before contacting the healthcare provider for further instructions.
• When teaching a female client to perform intermittent self-catheterization, the
nurseshould ensure the client's ability to perform which action?
• Locate the perineum.
• Transfer to a commode.
• Attach the catheter to a drainage bag.
• Manipulate a syringe to inflate the balloon.
Rationale: Adequate visualization or palpation of the perineum is essential to
ensure the correct placement of the catheter. During a self-catheterization, the client
typicallyallows the urine to drain into an open collection device, rather than a
drainage bag and uses a straight catheter without a balloon.
• A client who has moderate, persistent, chronic neuropathic pain due to diabetic
neuropathy takes gabapentin and ibuprofen daily. If Step 2 of the World Health
Organization (WHO) pain relief ladder is prescribed, which drug protocol should
be implemented?
• Continue gabapentin.
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Rationale: Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin, an antiseizure medication, may be used at any step for anxiety and
painmanagement, so continuing gabapentin should be implemented. Nonopioid
analgesics, such as ibuprofen and aspirin are Step 1 drugs. Steps 2 and 3 include
opioid narcotics, and to maintain freedom from pain, drugs should be given
aroundthe clock rather than by the client’s PRN requests.
• A male client with acquired immunodeficiency syndrome (AIDS) develops
cryptococcalmeningitis and tells the nurse he does not want to be resuscitated if his
breathing stops. Which action should the nurse implement?
• Document the client's request in the medical record.
• Ask the client if this decision has been discussed with his healthcare provider.
• Inform the client that a written, notarized advance directive, is required
to withhold resuscitation efforts.
ANSWERS WITH RATIONALES 2023 COMPLETE A+ GUIDE.
• Which client assessment data is most important for the nurse to consider
beforeambulating a postoperative client?
• Respiratory rate.
• Wound location.
• Pedal pulses.
• Pain rating.
Rationale: Mobilization and ambulation increase oxygen use, so it is most
importantto assess the client's respiratory rate before ambulation to determine
tolerance for activity.
• A signed consent form indicated a client should have an electromyogram, 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
likelyto rule in favor of the plaintiff because these events represent which infraction?
• A quasi-intentional tort because a similar mistake can happen to anyone.
• Failure to respect client autonomy to choose based on intentional tort law.
• Assault and battery with deliberate intent to deviate from the consent form.
• An unintentional tort because the client benefited from having the
myelogram. Rationale: The client was not properly informed of the procedure,
and failure to obtain informed consent constitutes assault and battery.
• A medication is prescribed to be given QID. Which schedule should the nurse use
to administer this prescription?
a. 0800, 1200, 1600, 2000.
b. 0800.
c. Every other day at 0800.
d. 0800, 1200, 1600, 2000, 0000, 0400.
Rationale: QID means four times per day.
• The nurse formulates the nursing problem of, "Ineffective health maintenance related
to lack of motivation" for a client with Type 2 diabetes. Which finding supports this
nursingproblem?
• Does not check capillary blood glucose as directed.
• Occasionally forgets to take daily prescribed medication.
• Cannot identify signs or symptoms of high and low blood glucose.
• Eats anything and does not think diet makes a difference in health.
Rationale: The nursing problem of ineffective health maintenance refers to
an inability to identify, manage, and/or seek out help to maintain health, and
is best
exemplified in the client's belief or understanding about diet and health maintenance.
• In providing care for a terminally ill resident of a long-term care facility, the
nurse determines that the resident is exhibiting signs of impending death and has
, a do notresuscitate or DNR status. Which intervention should the nurse
implement first?
• Request hospice care for the client.
• Report the client's acuity level to the nursing supervisor.
• Notify family members of the client's condition.
• Inform the chaplain that the client's death is imminent.
Rationale: The nurse's first priority is to notify the family of the resident's
impendingdeath.
• 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 noncompliant with the diet, based on which
report from the 24-hour dietary recall? (Select all that apply.)
• Snack of potato chips and diet soda.
• Lunch of tuna fish sandwich, carrot sticks, fresh fruit, and coffee.
• Breakfast of eggs, bacon, toast, and coffee.
• Dinner of vegetable lasagna, tossed salad, sherbet, and iced tea.
• Bedtime snack of crackers and milk.
Rationale: Potato chips are high in sodium. Tuna is high in protein. Bacon and
crackers are high in sodium.
• A client is admitted with a stage four pressure injury that has a black, hardened
surface(eschar) that is stable. Which dressing is best for the nurse to use first?
• Hydrogel.
• Exudate absorber.
• No dressing.
• Transparent adhesive film.
Rationale: If eschar is dry and intact and debridement is not part of the plan of
care, no dressing is used, allowing eschar to act as physiological cover.
• Which statement correctly identifies a written learning objective for a client
withperipheral vascular disease?
• The nurse will provide client instruction for daily foot care.
• The client will demonstrate proper trimming toenail technique.
• Upon discharge, the client will list three ways to protect the feet from injury.
• After instruction, the nurse will ensure the client understands the foot
carerationale.
Rationale: An objective should contain four elements: who will perform the
activity or acquire the desired behavior, the actual behavior that the learner will
exhibit, the condition under which the behavior is to be demonstrated, and the
specific criteria to be used to measure success. "Upon discharge, the client will list
three ways to protectthe feet from injury" is a concise statement that is a learning
objective that defines exactly how the client will demonstrate mastery of the
content.
, • The nurse determines a client's IV solution is infusing at 250 mL/hr. The prescribed
rateis 125 mL/hr. Which action should the nurse take first?
• Determine when the IV solution was started.
• Slow the IV infusion to keep vein open rate.
• Assess the IV insertion site for swelling.
• Report the finding to the healthcare provider.
Rationale: The nurse should first slow the IV flow rate to keep vein open (KVO)
rateto prevent further risk of fluid volume overload, then gather additional
assessment data, such as when the IV solution was started and the appearance of the
IV insertion site before contacting the healthcare provider for further instructions.
• When teaching a female client to perform intermittent self-catheterization, the
nurseshould ensure the client's ability to perform which action?
• Locate the perineum.
• Transfer to a commode.
• Attach the catheter to a drainage bag.
• Manipulate a syringe to inflate the balloon.
Rationale: Adequate visualization or palpation of the perineum is essential to
ensure the correct placement of the catheter. During a self-catheterization, the client
typicallyallows the urine to drain into an open collection device, rather than a
drainage bag and uses a straight catheter without a balloon.
• A client who has moderate, persistent, chronic neuropathic pain due to diabetic
neuropathy takes gabapentin and ibuprofen daily. If Step 2 of the World Health
Organization (WHO) pain relief ladder is prescribed, which drug protocol should
be implemented?
• Continue gabapentin.
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Rationale: Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin, an antiseizure medication, may be used at any step for anxiety and
painmanagement, so continuing gabapentin should be implemented. Nonopioid
analgesics, such as ibuprofen and aspirin are Step 1 drugs. Steps 2 and 3 include
opioid narcotics, and to maintain freedom from pain, drugs should be given
aroundthe clock rather than by the client’s PRN requests.
• A male client with acquired immunodeficiency syndrome (AIDS) develops
cryptococcalmeningitis and tells the nurse he does not want to be resuscitated if his
breathing stops. Which action should the nurse implement?
• Document the client's request in the medical record.
• Ask the client if this decision has been discussed with his healthcare provider.
• Inform the client that a written, notarized advance directive, is required
to withhold resuscitation efforts.
