HESI FUNDAMENTALS 2024 | ACCURATE REAL EXAM
QUESTIONS AND ANSWER | VERIFIED FOR
GUARANTEED PASS | GRADED A | LATEST UPDATE
The nurse plans to administer diazepam, 4 mg IV push, to a client with
severe anxiety. How many milliliters should the nurse administer? (Round
to the nearest tenth.)
A. 0.2 mL
B. 0.8 mL
C. 1.25 mL
D. 2.0 mL - ANS-B
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
The nurse prepares to insert a nasogastric tube in a client with
hyperemesis who is awake and alert. Which intervention(s) is(are)
correct? (Select all that apply.)
A. Place the client in a high Fowler position.
B. Help the client assume a left side-lying position.
C. Measure the tube from the tip of the nose to the umbilicus.
D. Instruct the client to swallow after the tube has passed the pharynx.
E. Assist the client in extending the neck back so the tube may enter the
larynx. - ANS-A, D
Rationale:
(A and D) are the correct steps to follow during nasogastric intubation.
Only the unconscious or obtunded client should be placed in a left side-
lying position (B). The tube should be measured from the tip of the nose to
behind the ear and then from behind the ear to the xiphoid process (C).
The neck should only be extended back prior to the tube passing the
pharynx and then the client should be instructed to position the neck
forward (E).
,The nurse teaches the use of a gait belt to a male caregiver whose wife
has right-sided weakness and needs assistance with ambulation. The
caregiver performs a return demonstration of the skill. Which observation
indicates that the caregiver has learned how to perform this procedure
correctly?
,When turning an immobile bedridden client without assistance, which
action by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - ANS-B
Rationale: Because the nurse can only stand on one side of the bed, bed
rails should be up on the opposite side to ensure that the client does not
fall out of bed. Option A can cause client injury to the skin or joint. Options
C and D are useful techniques while turning a client but have less priority
in terms of safety than use of the bed rails.
The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree) burns. What
intervention has the highest priority in decreasing the client's risk of
infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns - ANS-B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A
reverses the hypovolemia that initially accompanies burn trauma but is
not related to decreasing the proliferation of infective organisms. Options
C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent
infection.
, The nurse is aware that malnutrition is a common problem among clients
served by a community health clinic for the homeless. Which laboratory
value is the most reliable indicator of chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level - ANS-A
Rationale: Long-term protein deficiency is required to cause significantly
lowered serum albumin levels. Albumin is made by the liver only when
adequate amounts of amino acids (from protein breakdown) are
available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. Option B is a serum protein with a half-life
of only 8 to 10 days, so it will drop with an acute protein deficiency.
Options C and D are not clinical measures of protein malnutrition.
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. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the
client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before
the anesthesia is administered. - ANS-C
Rationale: The surgeon should be informed immediately that the permit is
not signed. It is the surgeon's responsibility to explain the procedure to
the client and obtain the client's signature on the permit. Although the
nurse can witness an operative permit, the procedure must first be
explained by the health care provider or surgeon, including answering the
client's questions. The client's questions should be addressed before the
permit is signed.
QUESTIONS AND ANSWER | VERIFIED FOR
GUARANTEED PASS | GRADED A | LATEST UPDATE
The nurse plans to administer diazepam, 4 mg IV push, to a client with
severe anxiety. How many milliliters should the nurse administer? (Round
to the nearest tenth.)
A. 0.2 mL
B. 0.8 mL
C. 1.25 mL
D. 2.0 mL - ANS-B
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
The nurse prepares to insert a nasogastric tube in a client with
hyperemesis who is awake and alert. Which intervention(s) is(are)
correct? (Select all that apply.)
A. Place the client in a high Fowler position.
B. Help the client assume a left side-lying position.
C. Measure the tube from the tip of the nose to the umbilicus.
D. Instruct the client to swallow after the tube has passed the pharynx.
E. Assist the client in extending the neck back so the tube may enter the
larynx. - ANS-A, D
Rationale:
(A and D) are the correct steps to follow during nasogastric intubation.
Only the unconscious or obtunded client should be placed in a left side-
lying position (B). The tube should be measured from the tip of the nose to
behind the ear and then from behind the ear to the xiphoid process (C).
The neck should only be extended back prior to the tube passing the
pharynx and then the client should be instructed to position the neck
forward (E).
,The nurse teaches the use of a gait belt to a male caregiver whose wife
has right-sided weakness and needs assistance with ambulation. The
caregiver performs a return demonstration of the skill. Which observation
indicates that the caregiver has learned how to perform this procedure
correctly?
,When turning an immobile bedridden client without assistance, which
action by the nurse best ensures client safety?
A. Securely grasp the client's arm and leg.
B. Put bed rails up on the side of bed opposite from the nurse.
C. Correctly position and use a turn sheet.
D. Lower the head of the client's bed slowly. - ANS-B
Rationale: Because the nurse can only stand on one side of the bed, bed
rails should be up on the opposite side to ensure that the client does not
fall out of bed. Option A can cause client injury to the skin or joint. Options
C and D are useful techniques while turning a client but have less priority
in terms of safety than use of the bed rails.
The nurse identifies a potential for infection in a client with partial-
thickness (second-degree) and full-thickness (third-degree) burns. What
intervention has the highest priority in decreasing the client's risk of
infection?
A. Administration of plasma expanders
B. Use of careful handwashing technique
C. Application of a topical antibacterial cream
D. Limiting visitors to the client with burns - ANS-B
Rationale: Careful handwashing technique is the single most effective
intervention for the prevention of contamination to all clients. Option A
reverses the hypovolemia that initially accompanies burn trauma but is
not related to decreasing the proliferation of infective organisms. Options
C and D are recommended by various burn centers as possible ways to
reduce the chance of infection. Option B is a proven technique to prevent
infection.
, The nurse is aware that malnutrition is a common problem among clients
served by a community health clinic for the homeless. Which laboratory
value is the most reliable indicator of chronic protein malnutrition?
A. Low serum albumin level
B. Low serum transferrin level
C. High hemoglobin level
D. High cholesterol level - ANS-A
Rationale: Long-term protein deficiency is required to cause significantly
lowered serum albumin levels. Albumin is made by the liver only when
adequate amounts of amino acids (from protein breakdown) are
available. Albumin has a long half-life, so acute protein loss does not
significantly alter serum levels. Option B is a serum protein with a half-life
of only 8 to 10 days, so it will drop with an acute protein deficiency.
Options C and D are not clinical measures of protein malnutrition.
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. Which action should the nurse take next?
A. Witness the client's signature to the permit.
B. Answer the client's questions about the surgery.
C. Inform the surgeon that the operative permit is not signed and the
client has questions about the surgery.
D. Reassure the client that the surgeon will answer any questions before
the anesthesia is administered. - ANS-C
Rationale: The surgeon should be informed immediately that the permit is
not signed. It is the surgeon's responsibility to explain the procedure to
the client and obtain the client's signature on the permit. Although the
nurse can witness an operative permit, the procedure must first be
explained by the health care provider or surgeon, including answering the
client's questions. The client's questions should be addressed before the
permit is signed.
