NRSG 3345 HESI Fundamentals Practice Test B Questions
With Complete Solutions
50.The nurse assesses an immobile, elderly male client and
determines that his blood pressure is 138/60, his temperature is
95.8° F, and his output is 100 ml of concentrated urine during
the last hour. He has wet-sounding lung sounds, and increased
respiratory secretions. Based on these assessment findings, what
nursing action is most important for the nurse to implement?
A. Administer a PRN antihypertensive prescription.
B. Provide the client with an additional blanket.
C. Encourage additional fluid intake.
D. Turn the client q2h. Correct Answer (D) will help to move
and drain respiratory secretions and prevent pneumonia from
occurring, so this intervention has the highest priority. Older
adults often have an increased BP, and a PRN antihypertensive
medication is usually prescribed for a BP over 140 systolic and
90 diastolic (A). Older adults often run a lower temperature,
particularly in the morning, and (B) does not have the priority of
(D). Even though the client has adequate output, (C) might be
encouraged because the urine is concentrated, but this
intervention does not have the priority of (D).
Correct Answer: D
51.The home health nurse visits an elderly female client who
had a brain attack three months ago and is now able to ambulate
with the assistance of a quad cane. Which assessment finding
has the greatest implications for this client's care?
A. The husband, who is the caregiver, begins to weep when the
nurse asks how he is doing.
,B. The client tells the nurse that she does not have much of an
appetite today.
C. The nurse notes that there are numerous scatter rugs
throughout the house.
D. The client's pulse rate is 10 beats higher than it was at the last
visit one week ago. Correct Answer Scatter rugs (C) pose a
safety hazard because the client can trip on them when
ambulating, so this finding has the greatest significance in
planning this client's care. Psychological support of the
caregiver (A) is a less acute need than that of client safety. The
nurse needs to obtain more information about (B), but this is not
a safety issue. (D) is not a significant increase, and additional
assessment might provide information about the reason for the
increase (anxiety, exercise, etc.).
Correct Answer: C
52.The nurse removes the dressing on a client's heel that is
covering a pressure sore one-inch in diameter and 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?
A. Stage 1 pressure sore draining sero-sanguineous drainage.
B. Pressure sore at bony prominence with exudate noted.
C. One-inch pressure sore draining serous fluid.
D. Pressure sore on heel with a small amount of purulent
drainage. Correct Answer Serous drainage is clear watery
plasma, so (C) provides accurate documentation based on the
information provided. Information to stage this pressure score
(A) is not provided, and sero-sanguineous drainage is pale and
watery with a combination of plasma and red cells, and may be
blood-streaked. Exudate (B) is fluid such as pus and serum.
,Purulent drainage (D) is thick, yellow, green, or brown
indicating the presence of dead or living organisms and white
blood cells.
Correct Answer: C
53.A medication is prescribed to be given QID. What schedule
should the nurse use to administer this prescription?
A. 0800, 1200, 1600, 2000.
B. 800.
C. Every other day at 0800.
D. 0800, 1200, 1600, 2000, 0000, 0400. Correct Answer (A)
provides the best schedule, because QID means four times per
day. (B, C, and D) provide incorrect dosages.
Correct Answer: A
54.The nurse working in the emergency department is assessing
four clients' ability to tolerate pain. Which client is likely to
tolerate a higher level of pain?
A. A 10-year-old who was burned by a camp fire earlier today.
B. A 70-year-old who has a postoperative infection from a
surgery one week ago.
C. A 23-year-old woman who sprained her knee while bicycling.
D. A 55-year-old woman who has had moderate low back pain
for three months. Correct Answer Experiences with the same
type of pain that has successfully been relieved makes it easier
for a client to interpret the pain sensation, and as a result, the
client is better prepared to take steps to relieve the pain (D). (A,
B, and C) are having new experiences with pain.
Correct Answer: D
, 55.A 4-year-old boy who is scheduled for a tonsillectomy and
adenoidectomy asks the nurse, Will it hurt to have my tonsils
and adenoids taken out? Which response is best for the nurse to
provide?
A. It may hurt a little because of the incision made in your
throat.
B. It won't hurt because you're such a big boy.
C. It won't hurt because we put you to sleep.
D. It may hurt but we'll give you medicine to help you feel
better. Correct Answer Answering questions simply and
directly provides comfort for the preschool-age child and builds
confidence in the health care team (D). (A) uses language (i.e.
'incision') that could create anxiety for the child. Four-year-olds
are in the Initiative vs. Guilt stage (Erikson's psychosocial
development), and (B) contributes to guilt when the child hurts.
(C) is not helpful because the child may associate being put to
sleep with the postoperative throat pain and then become fearful
of going to sleep.
Correct Answer: D
56.A female nurse who sometimes tries to save time by putting
medications in her uniform pocket to deliver to clients, confides
that after arriving home she found a hydrocodone (Vicoden)
tablet in her pocket. Which possible outcome of this situation
should be the nurse's greatest concern?
A. Accused of diversion.
B. Reported for stealing.
C. Reported for a HIPAA violation.
D. Accused of unprofessional conduct. Correct Answer Even
if this is only one incident, the nurse may be suspected of taking
medications on a regular basis and the incident could be
With Complete Solutions
50.The nurse assesses an immobile, elderly male client and
determines that his blood pressure is 138/60, his temperature is
95.8° F, and his output is 100 ml of concentrated urine during
the last hour. He has wet-sounding lung sounds, and increased
respiratory secretions. Based on these assessment findings, what
nursing action is most important for the nurse to implement?
A. Administer a PRN antihypertensive prescription.
B. Provide the client with an additional blanket.
C. Encourage additional fluid intake.
D. Turn the client q2h. Correct Answer (D) will help to move
and drain respiratory secretions and prevent pneumonia from
occurring, so this intervention has the highest priority. Older
adults often have an increased BP, and a PRN antihypertensive
medication is usually prescribed for a BP over 140 systolic and
90 diastolic (A). Older adults often run a lower temperature,
particularly in the morning, and (B) does not have the priority of
(D). Even though the client has adequate output, (C) might be
encouraged because the urine is concentrated, but this
intervention does not have the priority of (D).
Correct Answer: D
51.The home health nurse visits an elderly female client who
had a brain attack three months ago and is now able to ambulate
with the assistance of a quad cane. Which assessment finding
has the greatest implications for this client's care?
A. The husband, who is the caregiver, begins to weep when the
nurse asks how he is doing.
,B. The client tells the nurse that she does not have much of an
appetite today.
C. The nurse notes that there are numerous scatter rugs
throughout the house.
D. The client's pulse rate is 10 beats higher than it was at the last
visit one week ago. Correct Answer Scatter rugs (C) pose a
safety hazard because the client can trip on them when
ambulating, so this finding has the greatest significance in
planning this client's care. Psychological support of the
caregiver (A) is a less acute need than that of client safety. The
nurse needs to obtain more information about (B), but this is not
a safety issue. (D) is not a significant increase, and additional
assessment might provide information about the reason for the
increase (anxiety, exercise, etc.).
Correct Answer: C
52.The nurse removes the dressing on a client's heel that is
covering a pressure sore one-inch in diameter and 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?
A. Stage 1 pressure sore draining sero-sanguineous drainage.
B. Pressure sore at bony prominence with exudate noted.
C. One-inch pressure sore draining serous fluid.
D. Pressure sore on heel with a small amount of purulent
drainage. Correct Answer Serous drainage is clear watery
plasma, so (C) provides accurate documentation based on the
information provided. Information to stage this pressure score
(A) is not provided, and sero-sanguineous drainage is pale and
watery with a combination of plasma and red cells, and may be
blood-streaked. Exudate (B) is fluid such as pus and serum.
,Purulent drainage (D) is thick, yellow, green, or brown
indicating the presence of dead or living organisms and white
blood cells.
Correct Answer: C
53.A medication is prescribed to be given QID. What schedule
should the nurse use to administer this prescription?
A. 0800, 1200, 1600, 2000.
B. 800.
C. Every other day at 0800.
D. 0800, 1200, 1600, 2000, 0000, 0400. Correct Answer (A)
provides the best schedule, because QID means four times per
day. (B, C, and D) provide incorrect dosages.
Correct Answer: A
54.The nurse working in the emergency department is assessing
four clients' ability to tolerate pain. Which client is likely to
tolerate a higher level of pain?
A. A 10-year-old who was burned by a camp fire earlier today.
B. A 70-year-old who has a postoperative infection from a
surgery one week ago.
C. A 23-year-old woman who sprained her knee while bicycling.
D. A 55-year-old woman who has had moderate low back pain
for three months. Correct Answer Experiences with the same
type of pain that has successfully been relieved makes it easier
for a client to interpret the pain sensation, and as a result, the
client is better prepared to take steps to relieve the pain (D). (A,
B, and C) are having new experiences with pain.
Correct Answer: D
, 55.A 4-year-old boy who is scheduled for a tonsillectomy and
adenoidectomy asks the nurse, Will it hurt to have my tonsils
and adenoids taken out? Which response is best for the nurse to
provide?
A. It may hurt a little because of the incision made in your
throat.
B. It won't hurt because you're such a big boy.
C. It won't hurt because we put you to sleep.
D. It may hurt but we'll give you medicine to help you feel
better. Correct Answer Answering questions simply and
directly provides comfort for the preschool-age child and builds
confidence in the health care team (D). (A) uses language (i.e.
'incision') that could create anxiety for the child. Four-year-olds
are in the Initiative vs. Guilt stage (Erikson's psychosocial
development), and (B) contributes to guilt when the child hurts.
(C) is not helpful because the child may associate being put to
sleep with the postoperative throat pain and then become fearful
of going to sleep.
Correct Answer: D
56.A female nurse who sometimes tries to save time by putting
medications in her uniform pocket to deliver to clients, confides
that after arriving home she found a hydrocodone (Vicoden)
tablet in her pocket. Which possible outcome of this situation
should be the nurse's greatest concern?
A. Accused of diversion.
B. Reported for stealing.
C. Reported for a HIPAA violation.
D. Accused of unprofessional conduct. Correct Answer Even
if this is only one incident, the nurse may be suspected of taking
medications on a regular basis and the incident could be
