HESI FUNDAMENTALS EXAM 5 ACTUAL
EXAM QUESTIONS WITH DETAILED
VERIFIED CORRECT ANSWERS (GRADED
A+)
Which step(s) should the nurse take when administering ear drops to an adult client? (Select
all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
B
Rationale: The medication should be inhaled through the mouth simultaneously with
compression of the inhaler. This will facilitate the desired destination of the aerosol
medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do
not allow for deep lung penetration.
The nurse is instructing a 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? A. "Fill your
lungs with air through your mouth and then compress the inhaler."
B. "Compress the inhaler while slowly breathing in through your mouth."
C. "Compress the inhaler while inhaling quickly through your nose."
D. "Exhale completely after compressing the inhaler and then inhale."
D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
,should receive teaching first, respecting any personal beliefs such as cultural or spiritual
values. After client teaching, the client may still choose option A or B. Brochures reinforce
the teaching.
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3
days. She states, "I have been told that it is harmful to bathe during my period." Which action
should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.
A
Rationale: Option A offers an open-ended question most relevant to the client's statement.
Option B does not offer the client the opportunity to express concerns. Options C and D are
even less relevant to the client's statement.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes
that one of the side effects is a reduction in sexual drive. Which is the best response by the
nurse?
A. "How will this affect your present sexual activity?"
B. "How active is your current sex life?"
C. "How has your sex life changed as you have become older?"
D. "Tell me about your sexual needs as an older adult."
.A
Rationale: The client has demonstrated a purposeful response to pain, which should be
documented as such. Response to painful stimulus is assessed after response to verbal
stimulus, not before. There is no indication for placing the client on seizure precautions.
Reporting decorticate posturing to the health care provider is nonpurposeful movement.
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client
winces and pulls away from a painful stimulus. Which action should the nurse take next?
,A. Document that the client responds to painful stimulus.
B. Observe the client's response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider
B
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
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
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 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.
B
Rationale: His wife is most likely to lean toward the weak side and needs extra support on
, that side and from the back to prevent falling. Options A, C, and D provide less security
for her.
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?
A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any
evidence of weakness is observed.
B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt
from the back.
C. Standing behind his wife, the caregiver provides balance by holding both sides of the
gait belt.
D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by
gently pulling on the gait belt.
D
Rationale: Indwelling urinary catheters are a major source of infection. Options A and B
are both problems that may require an indwelling catheter. Option C is not affected by an
indwelling catheter.
Which nursing diagnosis has the highest priority when planning care for a client with an
indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection
A
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the
production of urine, thus decreasing the need to void at night. Option B helps prevent
bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia.
EXAM QUESTIONS WITH DETAILED
VERIFIED CORRECT ANSWERS (GRADED
A+)
Which step(s) should the nurse take when administering ear drops to an adult client? (Select
all that apply.)
A. Place the client in a side-lying position.
B. Pull the auricle upward and outward.
C. Hold the dropper 6 cm above the ear canal.
D. Place a cotton ball into the inner canal.
E. Pull the auricle down and back.
B
Rationale: The medication should be inhaled through the mouth simultaneously with
compression of the inhaler. This will facilitate the desired destination of the aerosol
medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do
not allow for deep lung penetration.
The nurse is instructing a 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? A. "Fill your
lungs with air through your mouth and then compress the inhaler."
B. "Compress the inhaler while slowly breathing in through your mouth."
C. "Compress the inhaler while inhaling quickly through your nose."
D. "Exhale completely after compressing the inhaler and then inhale."
D
Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client
,should receive teaching first, respecting any personal beliefs such as cultural or spiritual
values. After client teaching, the client may still choose option A or B. Brochures reinforce
the teaching.
A 20-year-old female client with a noticeable body odor has refused to shower for the last 3
days. She states, "I have been told that it is harmful to bathe during my period." Which action
should the nurse take first?
A. Accept and document the client's wish to refrain from bathing.
B. Offer to give the client a bed bath, avoiding the perineal area.
C. Obtain written brochures about menstruation to give to the client.
D. Teach the importance of personal hygiene during menstruation with the client.
A
Rationale: Option A offers an open-ended question most relevant to the client's statement.
Option B does not offer the client the opportunity to express concerns. Options C and D are
even less relevant to the client's statement.
While reviewing the side effects of a newly prescribed medication, a 72-year-old client notes
that one of the side effects is a reduction in sexual drive. Which is the best response by the
nurse?
A. "How will this affect your present sexual activity?"
B. "How active is your current sex life?"
C. "How has your sex life changed as you have become older?"
D. "Tell me about your sexual needs as an older adult."
.A
Rationale: The client has demonstrated a purposeful response to pain, which should be
documented as such. Response to painful stimulus is assessed after response to verbal
stimulus, not before. There is no indication for placing the client on seizure precautions.
Reporting decorticate posturing to the health care provider is nonpurposeful movement.
The nurse is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client
winces and pulls away from a painful stimulus. Which action should the nurse take next?
,A. Document that the client responds to painful stimulus.
B. Observe the client's response to verbal stimulation.
C. Place the client on seizure precautions for 24 hours.
D. Report decorticate posturing to the health care provider
B
Rationale: (1 mL × 4 mg)/5 mg = 0.8 mL
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
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 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.
B
Rationale: His wife is most likely to lean toward the weak side and needs extra support on
, that side and from the back to prevent falling. Options A, C, and D provide less security
for her.
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?
A. Standing on his wife's strong side, the caregiver is ready to hold the gait belt if any
evidence of weakness is observed.
B. Standing on his wife's weak side, the caregiver provides security by holding the gait belt
from the back.
C. Standing behind his wife, the caregiver provides balance by holding both sides of the
gait belt.
D. Standing slightly in front and to the right of his wife, the caregiver guides her forward by
gently pulling on the gait belt.
D
Rationale: Indwelling urinary catheters are a major source of infection. Options A and B
are both problems that may require an indwelling catheter. Option C is not affected by an
indwelling catheter.
Which nursing diagnosis has the highest priority when planning care for a client with an
indwelling urinary catheter?
A. Self-care deficit
B. Functional incontinence
C. Fluid volume deficit
D. High risk for infection
A
Rationale: Nocturia is urination during the night. Option A is helpful to decrease the
production of urine, thus decreasing the need to void at night. Option B helps prevent
bladder infections. Option C may promote sleep, but the fluid will contribute to nocturia.
