HESI NCLEX-RN Fundamentals, Question
well done, 2023/2024
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the
greatest threat for complications to occur during surgery? - answersTaking anticoagulants for the past
year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for developing
surgical complications. The healthcare provider should be informed that the client is taking such drugs.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8
hours. The nurse inserts the catheter, but no urine is seen in the tubing. What action will the nurse take
next? - answersLeave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in
place will help locate the meatus when attempting the second catheterization
The nurse is instructing a male client in the proper use of a metered-dose inhaler. Which instruction
should the nurse provide the client to ensure the optimal benefits from the drug? - answersCompress
the inhaler while slowly breathing in through your mouth.
Rationale:
The medication should be inhaled through the mouth simultaneously with compression of the inhaler
The nurse is assisting a male client to the bathroom. When 5 feet from the bathroom door, the client
states, "I feel faint." Before the nurse can get him to a chair, he starts to fall. What is the priority action
for the nurse to take? - answersGently lower the client to the floor.
Rationale:
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and
the nurse. Lowering the client to the floor should be done when the client cannot support his own
weight. The client should be placed in a bed or chair only when sufficient help is available to prevent
injury.
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling
urinary catheter? - answersHigh risk for infection
,Rationale:
Indwelling urinary catheters are a major source of infection
A nurse is working in an occupational health clinic when a male employee walks in and states that he
was struck by lightning while working on his truck bed. He is alert but reports feeling faint. What
assessment will the nurse perform first? - answersPulse characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the
pulse rate and regularity (A) is a priority. Since the client is talking, he has an open airway
The nurse makes the nursing diagnosis of Potential for infection related to partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing
the client's risk of infection? - answersUse of careful handwashing technique
Rationale:
Careful handwashing technique (B) is the single most effective intervention for prevention of
contamination to all clients.
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first
sound was heard. What is the best action for the nurse to take? - answersDeflate the cuff to zero and
wait 30 to 60 seconds before reattempting the reading.
Rationale:
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so that an
accurate reading can be obtained on that extremity a second time.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure in the lower
extremity. Which observation of this procedure requires the nurse's intervention? - answersThe UAP
auscultates the popliteal pulse with the cuff on the lower leg.
Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for
auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with
the UAP who has applied the cuff on the lower leg
In taking a client's history, the nurse asks about the stool characteristics. Which description should the
nurse report to the healthcare provider as soon as possible? - answersDaily black, sticky stool
, Rationale:
Black, sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the
healthcare provider promptly
The nurse is teaching a male client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports that he is still unable to sleep despite following the same
routine every night. What action should the nurse take first? - answersAsk the client to describe the
routine he is currently following.
Rationale:
The nurse should first evaluate whether the client has been adhering to the original instructions
By rolling contaminated gloves inside out, the nurse is impacting which step in the chain of infection? -
answersMode of transmission
Rationale:
The contaminated gloves serve as the mode of transmission
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following
surgery and notes that an antihypertensive medication prescribed preoperatively is not listed. What
action should the nurse take? - answersContact the healthcare provider to renew the prescription for
the medication.
Rationale:
Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact
the healthcare provider if the antihypertensive medication is not included in the postoperative
prescriptions
In assisting an older adult client prepare to take a tub bath, which nursing action is most important? -
answersCheck the bath water temperature.
Rationale:
To prevent burns or excessive chilling, the nurse must check the bath water temperature
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The
client begins to ask more questions about the surgical procedure. What action should the nurse take
next? - answersInform the surgeon the operative permit is not signed and the client has questions about
the surgery.
well done, 2023/2024
The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the
greatest threat for complications to occur during surgery? - answersTaking anticoagulants for the past
year
Rationale:
Anticoagulants (B) increase the risk for bleeding during surgery, which can pose a threat for developing
surgical complications. The healthcare provider should be informed that the client is taking such drugs.
Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8
hours. The nurse inserts the catheter, but no urine is seen in the tubing. What action will the nurse take
next? - answersLeave the catheter in place and reattempt with another catheter.
Rationale:
It is likely that the first catheter is in the vagina, rather than the bladder. Leaving the first catheter in
place will help locate the meatus when attempting the second catheterization
The nurse is instructing a male client in the proper use of a metered-dose inhaler. Which instruction
should the nurse provide the client to ensure the optimal benefits from the drug? - answersCompress
the inhaler while slowly breathing in through your mouth.
Rationale:
The medication should be inhaled through the mouth simultaneously with compression of the inhaler
The nurse is assisting a male client to the bathroom. When 5 feet from the bathroom door, the client
states, "I feel faint." Before the nurse can get him to a chair, he starts to fall. What is the priority action
for the nurse to take? - answersGently lower the client to the floor.
Rationale:
(D) is the most prudent intervention and is the priority nursing action to prevent injury to the client and
the nurse. Lowering the client to the floor should be done when the client cannot support his own
weight. The client should be placed in a bed or chair only when sufficient help is available to prevent
injury.
Which nursing diagnosis has the highest priority when planning care for a client with an indwelling
urinary catheter? - answersHigh risk for infection
,Rationale:
Indwelling urinary catheters are a major source of infection
A nurse is working in an occupational health clinic when a male employee walks in and states that he
was struck by lightning while working on his truck bed. He is alert but reports feeling faint. What
assessment will the nurse perform first? - answersPulse characteristics
Rationale:
Lightning is a jolt of electrical current and can produce a "natural" defibrillation, so assessment of the
pulse rate and regularity (A) is a priority. Since the client is talking, he has an open airway
The nurse makes the nursing diagnosis of Potential for infection related to partial-thickness (second-
degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing
the client's risk of infection? - answersUse of careful handwashing technique
Rationale:
Careful handwashing technique (B) is the single most effective intervention for prevention of
contamination to all clients.
When taking a client's blood pressure, the nurse is unable to distinguish the point at which the first
sound was heard. What is the best action for the nurse to take? - answersDeflate the cuff to zero and
wait 30 to 60 seconds before reattempting the reading.
Rationale:
Deflating the cuff for 30 to 60 seconds (C) allows blood flow to return to the extremity so that an
accurate reading can be obtained on that extremity a second time.
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure in the lower
extremity. Which observation of this procedure requires the nurse's intervention? - answersThe UAP
auscultates the popliteal pulse with the cuff on the lower leg.
Rationale:
When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for
auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with
the UAP who has applied the cuff on the lower leg
In taking a client's history, the nurse asks about the stool characteristics. Which description should the
nurse report to the healthcare provider as soon as possible? - answersDaily black, sticky stool
, Rationale:
Black, sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the
healthcare provider promptly
The nurse is teaching a male client how to perform progressive muscle relaxation techniques to relieve
insomnia. A week later the client reports that he is still unable to sleep despite following the same
routine every night. What action should the nurse take first? - answersAsk the client to describe the
routine he is currently following.
Rationale:
The nurse should first evaluate whether the client has been adhering to the original instructions
By rolling contaminated gloves inside out, the nurse is impacting which step in the chain of infection? -
answersMode of transmission
Rationale:
The contaminated gloves serve as the mode of transmission
The nurse transcribes the postoperative prescriptions for a client who returns to the unit following
surgery and notes that an antihypertensive medication prescribed preoperatively is not listed. What
action should the nurse take? - answersContact the healthcare provider to renew the prescription for
the medication.
Rationale:
Medications prescribed preoperatively must be renewed postoperatively, so the nurse should contact
the healthcare provider if the antihypertensive medication is not included in the postoperative
prescriptions
In assisting an older adult client prepare to take a tub bath, which nursing action is most important? -
answersCheck the bath water temperature.
Rationale:
To prevent burns or excessive chilling, the nurse must check the bath water temperature
In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The
client begins to ask more questions about the surgical procedure. What action should the nurse take
next? - answersInform the surgeon the operative permit is not signed and the client has questions about
the surgery.
