Hesi Fundamentals Practice Test Evolve Practice Test ( 2021 22 latest update ) Q&A

HESI RN FUNDAMENTALS TESTBANK
g g g




AgpostoperativegclientghasgthreegdifferentgPRNganalgesicsgprescribedgforgdifferentglevelsgofgpain.gThegnurseginadverte
ntlygadministergagdosegthatgisgnotgwithingthegprescribedgparameters.gWhatgactiongshouldgthegnursegtakefirst?g C
A) Determinegifgthegpaingwasgrelieved.
B) Completegagmedicationgerrorgreport.
C) Assessgforgsidegeffectsgofgthegmedication.
D) Documentgthegclientsgresponses.


Thegunlicensedgassistivegpersonnelg(UAP)gdescribesgthegappearancegofgthegbowelgmovementsgofgseveralclient
s.gWhichgdescriptionsgwarrantgadditionalgfollow-upgbygthegnurse?g(Selectgallgthatgapply.) ABDE
A) Multipleghardgpellets.
B) Browngliquid.
C) Formedgbutgsoft.
D) Solidgwithgredgstreaks.
E) Tarrygappearance.

Angelderlygwomangcomesgtogthegclinicgbecausegofgvaginalgbleeding.gTheghealthcaregprovidergfindsgagvaginalgtear,whic
hgthegclientgreportsgisglikelygtoghavegoccurredgduringgunprotectedgsexualgintercourse.gWhichgcontentgisgmostgimporta
ntgforgthegnursegtogincludegingthisgclient’sgteachinggplan? A
A) Thegimportancegofgusinggvaginalglubricants.
B) Methodsgusedgtogpracticegsafegsex.
C) Informationgaboutgalternativegwaysgtogexpressgsexuality.
D) Intercoursegpositionsgthatghelpgpreventgtears.


Agmalegclientghasgright-
sidedghemiplegiagfollowinggagleftgcerebrovasculargaccidentg(CVA).gHisgsittinggbalanceghasimproved,gandghegisgnowgable
gtogsitgIngagwheelchair.gTogassistgthegclientgingtransferringgfromgthegbedgtogagwheelchair,gwhatgaction gshouldgthegnursegta
ke?
A) Havegthegclientgputgbothgarmsgaroundgthegnurse’sgneckgforgsupport.B)gPl
aceggthegwheelchairgongthegclient’sgleftgside.
C) Instructgthegclientgtoglookgatghisgfeet.
D) Instructgthegclientgtotalgslow,gdeepgbreathsgwhilegtransferring.

Thegnursegobservesgagnewlygadmittedgoldergadultgfemalegtakegshortgstepsgandgwalkgverygslowlygwhilegpushinggawal
kergingfrontgofgher.gWhatgactiongshouldgthegnursegtakegingresponsegtogthesegobservations? A
A) Completegagfullgfallgriskgassessmentgofgthegclient.
B) Teachgthegclientgtogtakeglongergstepsgatgfastergpace.
C) Suggestgthatgthegthegclientgusegagwheelchairginsteadgofgagwalker.
D) Placegclientgongbedrestguntilgtheghealthcaregprovidergisgnotified.


Agclientgisgreceivinggketorolacg(Toradol)gIMg45gmggIMg6ghoursgforgpostoperativegpain.gThegavailableg2gmlgvialgislabel
edg,gToradolgIMg30gmg/ml,gHowgmanygshouldgthegnursegadminister?
(Roundgtogthegnearestgtenth.) 1.5mg

Whilegsuctioninggagclient’sgnasopharynx,gthegnursegobservesgthatgthegclient’sgoxygengsaturationgremainsgatg94%,which
gisgthegsamegreadinggobtainedgpriorgtogstartinggthegprocedure.gWhatgactiongshouldgthegnursegtakeging responsegtogthisgfi
nding?
C
A) Repositiongthegpulsegoximetergclipgtogobtaingagnewgreading.
B) Stopgsuctioningguntilgthegpulsegoximetergreadinggisgaboveg95%.
C)ggCompletegthegintermittentgsuctiongofgthegnasopharynx.
D)gApplygangoxygengmaskgovergthegclient’sgnosegandgmouth.

,Angoldergwomangwithgendgstagegheartgdiseasegisghospitalizedgforgseveregheartgfailure.gShegisgalert,goriented,gandrequest
sgthatgnogheroicgmeasuresgaregimplementedgifghergbreathinggstops.gWhatgactiongshouldgthegnursegtakegfirst? A
A) Discussgwithgthegclientghergmeaninggofgheroicgmeasures.
B) Obtaingag“dognotgresuscitate”g(DNR)gprescription.
C) Setgupgagfamilygconferencegtogdiscussgthegclient’s.
D) Consultgthegpalliativegcaregteamgaboutgclient’sgcare.

Agclientgdiagnosedgwithgprimarygopen-
anglegglaucomagreceivedgagprescriptiongforgbioticgeyegdrops,gpilocarpineHClg(Pilocarpine).gWhatginstructiongsh
ouldgthegnursegplangtogincludegingthisgclient’sgteaching? A
A) “Dognotgallowgthegdroppergbottlegtogtouchgthegeye.”
B) “Administergthegmedicationgdirectlygongthegcornea.”
C) “Squeezegyourgeyegclosedgaftergadministeringgthegdrops.”
D) “Washgyourghandsgaftergeachgadministrationgofgeyegdrops.”

Whengassessinggagclientgwhogstartsgtogwheezegrelatedgdatagshouldgobtain? D
A) Presencegofgradiation.
B) Heartgsounds.
C) Bodygtemperature.gD)
ggPrecipitatinggfactors.



Theghomeghealthgnursegisgreviewinggthegpersonalgcaregofgangelderlygclientgwhoglivesgalone.Whichgclientgassess
mentgfindingsgindicategthegneedgtogassigngangunlicensedgassistivegpersonnel.g(UAP)gtogprovidegroutinefootgcarega
ndgfilegthegclient’sgtoenails?gSelectgallgthatgapply.) ABC
A)gsyncopegwhengbending.B)
ggHandgtremors.
C) Diminishedgvisualgacuity.
D) Urinarygincontinence.
E) Shufflingggait.

Agclientgisgdischargedgtogaglong-
termgcaregfacilitygwithgangindwellinggurinarygcatheter.gWhichgnursinggactionshouldgbegincludedgingthegplangtog
reducegthegclient’sgriskgforginfectiongrelatedgtogthegcatheter? B
A) Flushgthegcathetergdailygwithgsterilegsaline.B
)ggEncouragegincreasedgintakegofgoralgfluids.
C) AdministergagPRNgantipyreticgifgagfevergdevelops.
D) Securegthegdrainagegbaggatgbladderglevelgduringgtransport.


Togassessgthegqualitygofgangadultgclient’sgpain,gwhatgapproachgshouldgthegnurseguse? C
A) Observegbodyglanguagegandgmovement.
B) Providegagnumericgpaingscale.
C) Askgthegclientgtogdescribegthegpain.
D) Identifygeffectivegpaingreliefgmeasures.

Agclientgwhoghasgbeengdiagnosedgwithgterminalgcancergtellsgthegnurse,g“ThegdoctorgtoldgmegIghavegcancergandgdonotghav
eglonggtoglive.”gWhichgresponsegisgbestgforgthegnursegtogprovide?
A) “That’sgcorrect,gyougdognotghaveglonggtoglive” D
B) “Wouldgyouglikegmegtogcallgyourgminister?”
C) “Don'tggivegup,gyougstillghavegchemotherapygtogtry.”
D)gg“Yes,gyourgconditiongisgserious.”


Whengperforminggbloodgpressuregmeasurementgtogassessgforgorthostaticghypotension,gwhichgactiongshouldgthen
ursegimplementgfirst? C
A) Applygthegbloodgpressuregcuffgsecurely.
B) Recordgthegclient’sgpulsegrategandgrhythm.g
C)ggPositiongthegclientgsupinegforgagfewgminute
s.
D) Assistgthegclientgtogstandgatgbedside.

,Agfemalegunlicensedgassistivegpersonnelg(UAP)gisgassignedgtogtakegthegvitalgsignsgofgagclientgwithgpertussisgforg whomg
dropletgprecautionsghavegbeengimplemented.gThegUAPgrequestgagchangegingassignment,gstatinggsheghasnotgyetgbeengfitte
dgforgagparticulategfiltergmask.gWhatgactiongshouldgthegnursegtake? D


Whengevaluatinggthegeffectivenessgofgagclient’sgnursinggcare,gthegnursegfirstgreviews
gthegexpectedgoutcomesgidentifiedgingthegplangofgcare.gWhatgactiongshouldgthegnurse

gtakegnext?
A) Modifygthegnursingginterventionsgtogachievegthegclientsggoals.
B) Determinegifgthegexpectedgoutcomesgweregrealistic.
C) Revi ewgrelatedgprofessionalgstandardsgofgcar
D) e.Obtaingcurrentgclientgdatagtogcomparegwithgexpectedgoutcomes.

Agpolicygrequiringgthegremovalgofgacrylicgnailsgbygallgnursinggpersonnelgwasgimple
mentedgsixgmonthsgago.gWhichassessmentgmeasuregbestgdeterminesgifgthegintended
goutcomegofgthegpolicygisgbeinggachieved?
A) Numbergofgthegstaff-inducedgskinginjuries.
B) Clientgsatisfactiongsurvey.
C) Rategofgneedlestickginjuriesgbygnurses.
D) Healthcare-associatedg infectiong rates.



Agclientgwithglimitedgtolerancegforgactivitygneedsgtogwalkgingtheghallwaygwithgassis
tance.gWhichginstructionsgshouldgthegnurseggivegtogthegunlicensedgassisstivegperson
nelg(UAP)gwhogassisstinggwithgclient’sgcare?g(Selectgallgthatgapply.)
A) Instructgthegclientgaboutgsignsgofgorthostaticghypertension
B) Determineg ifg theg clientg needsg tog haveg ag gaitg beltg appliedgC)g
gMeasureg theg clientsg vitalg signsg beforeg theg clientg walks.gD)gOffe
rgtoggassistgthegclientgtogvoidgpriorgtogwalkinggingtheghall.E)gRepo
rtgtheggonsetgofganygdizzinessgorglightgheadedness.


Agclientghasgbegungaglong-
termgmaintenancegtherapygwithglithium,gwhichghasgagnarrowgtherapeuticgindex.
gWhichgadversegeffectgisgmostgimportantgforgnursegtogincludegingthegteachinggpl

an?
A)gDependence.
B) Toxicity.
C) Interaction.
D) Tolerance.



Whileginterviewinggagclient,gthegnursegrecordsgthegassessmentgingthegelectronicghealth
grecord.gWhichgstatementgisgmostgaccurategregardinggelectronicgdocumentationgdurin

gganginterview?
A) Theginterviewgprocessgisgenhancedgwithgelectronicgdocumentationgandgallowsgthegclientgtogspeakgatgagnormalgpace.
B) Completinggthegelectronicgrecordgduringganginterviewgisgaglegalgobligationgofgthegexamininggnurse.
C) Thegnurseghasglimitedgabilitygtogobservegnonverbalgcommunicationg
gwhilegenteringgthegassessmentgelectronically.
D) Thegclient’sgcomfortglevelgisgincreasedgwhengthegnursegbreaksgeyegcontactgtogtypegnotesgintogthegrecord.


Agclientgwhoglivesgingangassistedglivinggfacilitygdevelopsgcognitivegimpairmentgfoll
owinggagstroke.gInformedgconsentgisneededgtogprovidegadditionalgnursinggservices.
gWhogshouldgnursegcontact?

, A) Thegclient’sgoldestglivinggchild,gaglawyer,gwhogisgvisitinggfromgoutgofgtown.
B) Agdaughterg-in-lawgdesignatedgasgthegclient’sgDurablegPowergofgAttorneyg(DPOA).
C) Thegclient’sgyoungestgson,gidentifiedgbygfamilygmembersgasgthegfamilygspokesperson.
D) Thegclient’sgspousegwhoglivesgingthegindependentglivinggunitgofgthegfacility.



AgclientgisgingcontactgisolationgduegtogstagegIVgcoccyxgwoundginfectedgwithgmethici
llingresistantgstaphylococcusgaureus(MRSA).gThegnursegplansginterventionsgtogprev
entgmultiplegre-
entriesgtogthegclient’sgroom.gIngwhichgordergshouldgthegnursegperformgtheginterventi
ons?
A) Changegcoccyxgdressing,gperformgtracheostomygcare,grestartgthegIV.
B) Performgtracheostomygcare,gchangegcoccyxgdressing,grestartgthegIV.
C) RestartgthegIV,gperformgtracheotomygcare,gchangegcoccyxgdressing.
D) Changegcoccyxgdressing,grestartgthegIV,gperformgtracheostomygcare.




Whatgself-
caregoutcomegisgbestgforgthegnursegtogusegingevaluatinggagclient’sgrecoverygformgagstro
kegthatgresultedgingleft-gsidedghemiparesis?
A) Promotegindependencegbygallowinggclientgtogperformgallgself-caregactivities.
B) Participatesgingself-caregtogoptimalglevelgofgcapacity.