HESI Fundamentals Practice Exam 1 Questions
and Correct Answers, With Complete Solution.
A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled
chemo & states that she's ready to go home to die. What intervention should the
nurse initiate?
Evaluate the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot
document until the HCP is notified of the patient's wishes & a d/c RX is obtained.
Advance directives & DNR are not necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior
to a surgical procedure. Which laboratory test indicates client's protein status for
the longest length of time?
Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance
with bathing?
"I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces?
Place the soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest
priority?
Impaired gas exchange
The nurse assesses an immobile, elderly male client & determines that his blood
pressure is 138/60, his temperature is 95.8F & his output is 100 mL of
concentrated urine during the last hour. He has wet sounding lungs & increased
respiratory secretions. Based on these assessment findings , what nursing action
is most important for the nurse to implement?
Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from
occurring.
The home health nurse visits an elderly female client who had a brain attack 3
months ago & is now able to ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this client's care?
The nurse notes there are numerous scatter rugs throughout the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1"
in diameter & 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?
One-inch pressure sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to
administer this Rx?
, 0800, 1200, 1600, 2000
The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which
client is likely to tolerate a higher level of pain?
1 55y/o woman who has had moderate low back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been relieved
makes it easier for the client to interpret the pain sensation and, as a result, the client is
better prepared to take steps to relieve the pain. All other clients are having new
experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the
nurse, "Will it hurt to have my tonsils & adenoids taken out?" Which response is
best for the nurse to provide?
"It may hurt, but we'll give you medicine to help you feel better."
A low-sodium, low-protein diet is prescribed for a 45y/o client with renal
insufficiency & HTN, who gained 3lbs in the last month. The nurse determines
that the client has been noncompliant with the diet, based on which report from
the 24hr diet recall?
1. Snack of potato chips & diet soda
2. Lunch of tuna, carrots, fruit & coffee
3. Breakfast of eggs, bacon, toast & coffee
4. Bedtime snack of crackers & milk
What intervention should the nurse include in the care plan for a client who is
being treated with an Unna's paste boot for leg ulcers due to chronic venous
insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot
Rationale: Boot becomes rigid after it dries, so it is important to check distally for
adequate circulation. No bandage should be put under it. Should be applied from foot &
wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly
removal is reasonable.
Male client with nursing diagnosis of "spiritual distress". What intervention is
best for the nurse to implement when caring for this client?
Use reflective listening techniques when the client expresses spiritual doubts.
Rationale: Client should be consulted before involving chaplain.
Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to
impending death." What intervention is best for the nurse to implement when
caring for this client?
Assist & support the client in establishing short-term goals.
Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to
death.
and Correct Answers, With Complete Solution.
A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled
chemo & states that she's ready to go home to die. What intervention should the
nurse initiate?
Evaluate the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot
document until the HCP is notified of the patient's wishes & a d/c RX is obtained.
Advance directives & DNR are not necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior
to a surgical procedure. Which laboratory test indicates client's protein status for
the longest length of time?
Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance
with bathing?
"I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces?
Place the soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest
priority?
Impaired gas exchange
The nurse assesses an immobile, elderly male client & determines that his blood
pressure is 138/60, his temperature is 95.8F & his output is 100 mL of
concentrated urine during the last hour. He has wet sounding lungs & increased
respiratory secretions. Based on these assessment findings , what nursing action
is most important for the nurse to implement?
Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from
occurring.
The home health nurse visits an elderly female client who had a brain attack 3
months ago & is now able to ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this client's care?
The nurse notes there are numerous scatter rugs throughout the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1"
in diameter & 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?
One-inch pressure sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to
administer this Rx?
, 0800, 1200, 1600, 2000
The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which
client is likely to tolerate a higher level of pain?
1 55y/o woman who has had moderate low back pain for 3 months
Rationale: Experiences with the same type of pain that has successfully been relieved
makes it easier for the client to interpret the pain sensation and, as a result, the client is
better prepared to take steps to relieve the pain. All other clients are having new
experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the
nurse, "Will it hurt to have my tonsils & adenoids taken out?" Which response is
best for the nurse to provide?
"It may hurt, but we'll give you medicine to help you feel better."
A low-sodium, low-protein diet is prescribed for a 45y/o client with renal
insufficiency & HTN, who gained 3lbs in the last month. The nurse determines
that the client has been noncompliant with the diet, based on which report from
the 24hr diet recall?
1. Snack of potato chips & diet soda
2. Lunch of tuna, carrots, fruit & coffee
3. Breakfast of eggs, bacon, toast & coffee
4. Bedtime snack of crackers & milk
What intervention should the nurse include in the care plan for a client who is
being treated with an Unna's paste boot for leg ulcers due to chronic venous
insufficiency?
Check capillary refill of toes on lower extremity with Unna's paste boot
Rationale: Boot becomes rigid after it dries, so it is important to check distally for
adequate circulation. No bandage should be put under it. Should be applied from foot &
wrapped towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly
removal is reasonable.
Male client with nursing diagnosis of "spiritual distress". What intervention is
best for the nurse to implement when caring for this client?
Use reflective listening techniques when the client expresses spiritual doubts.
Rationale: Client should be consulted before involving chaplain.
Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to
impending death." What intervention is best for the nurse to implement when
caring for this client?
Assist & support the client in establishing short-term goals.
Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to
death.
