HESI FUNDAMENTALS PRACTICE . Questions with 100% Correct Answers.

1. Which drug does a nurse anticipate may be prescribed to produce diuresis and inhibit formation of aqueous humor for a client with glaucoma? Chlorothiazide (Diuril) Acetazolamide (Diamox) Bendroflumethiazide (Naturetin) Demecarium bromide (Humorsol) 2. A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. 3. A client receiving steroid therapy states, "I have difficulty controlling my temper which is so unlike me, and I don't know why this is happening." What is the nurse's best response? Tell the client it is nothing to worry about. Talk with the client further to identify the specific cause of the problem. Instruct the client to attempt to avoid situations that cause irritation. Interview the client to determine whether other mood swings are being experienced. 4. The nurse is caring for a client with a temperature of 104.5 degrees Fahrenheit. The nurse applies a cooling blanket and administers an antipyretic medication. The nurse explains that the rationale for these interventions is to: Promote equalization of osmotic pressures. Prevent hypoxia associated with diaphoresis. Promote integrity of intracerebral neurons. Reduce brain metabolism and limit hypoxia. 5. A health care provider prescribes 500 mg of an antibiotic intravenous piggyback (IVPB) every 12 hours. The vial of antibiotic contains 1 g and indicates that the addition of 2.5 mL of sterile water will yield 3 mL of reconstituted solution. How many milliliters of the antibiotic should be added to the 50 mL IVPB bag? Record your answer using one decimal place. __ mL 1.5 6. The nurse is caring for a non-ambulatory client with a reddened sacrum that is unrelieved by repositioning. What nursing diagnosis should be included on the client's plan of care? Risk for pressure ulcer Risk for impaired skin integrity Impaired skin integrity, related to infrequent turning and repositioning Impaired skin integrity, related to the effects of pressure and shearing force 7. A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcer? Stage I Stage II Stage III Unstageable A client is being admitted for a total hip replacement. When is it necessary for the nurse to ensure that a medication reconciliation is completed? Select all that apply. After reporting severe pain On admission to the hospital Upon entering the operating room Before transfer to a rehabilitation facility At time of scheduling for the surgical procedure 8. A client is taking lithium sodium (Lithium). The nurse should notify the health care provider for which of the following laboratory values? White blood cell (WBC) count of 15,000 mm3 Negative protein in the urine Blood urea nitrogen (BUN) of 20 mg/dL Prothrombin of 12.0 seconds 10. Often when a family member is dying, the client and the family are at different stages of grieving. During which stage of a client's grieving is the family likely to require more emotional nursing care than the client? Anger Denial Depression Acceptance . 9. The client asks the nurse to recommend foods that might be included in a diet for diverticular disease. Which foods would be appropriate to include in the teaching plan? Select all that apply. Whole grains Cooked fruit and vegetables Nuts and seeds Lean red meats Milk and eggs 10. A nurse is obtaining a health history from the newly admitted client who has chronic pain in the knee. What should the nurse include in the pain assessment? Select all that apply. Pain history, including location, intensity, and quality of pain Client's purposeful body movement in arranging the papers on the bedside table Pain pattern, including precipitating and alleviating factors Vital signs such as increased blood pressure and heart rate The client's family statement about increases in pain with ambulation 11. enema, the client reports abdominal cramping. What action should the nurse take? Immediately stop the infusion. Lower the height of the enema bag. Advance the enema tubing 2 to 3 inches. Clamp the tube for 2 minutes, then restart the infusion. . 12. During the initial physical assessment of a newly admitted client with a pressure ulcer, a nurse observes that the client's skin is dry and scaly. The nurse applies emollients and reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate? The nurse also should have instituted a plan to increase activity. The nurse provided supportive nursing care for the well-being of the client. Debridement of the pressure ulcer should have been done before the dressing was applied Treatment should not have been instituted until the health care provider's prescriptions were received. A visitor comes to the nursing station and tells the nurse that a client and his relative had a fight and that the client is now lying unconscious on the floor. What is the most important action the nurse needs to take? Ask the client if he is okay. Call security from the room. Find out if there is anyone else in the room. Ask security to make sure the room is safe To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse should change the administration set every: 4 to 8 hours 12 to 24 hours 24 to 48 hours 72 to 96 hours 13. A nurse is taking care of a client who has severe back pain as a result of a work injury. What nursing considerations should be made when determining the client's plan of care? Select all that apply. Ask the client what is the client's acceptable level of pain. Eliminate all activities that precipitate the pain. Administer the pain medications regularly around the clock. Use a different pain scale each time to promote patient education. Assess the client's pain every 15 minutes 14. The nurse is preparing to administer eardrops to a client that has impacted cerumen. Before administering the drops, the nurse will assess the client for which contraindications? Select all that apply. Allergy to the medication Itching in the ear canal Drainage from the ear canal Tympanic membrane rupture Partial hearing loss in the affected ear What clinical indicators should the nurse expect a client with hyperkalemia to exhibit? Select all that apply. Tetany Seizures Diarrhea Weakness Dysrhythmias . 15. A health care provider has prescribed isoniazid (Laniazid) for a client. Which instruction should the nurse give the client about this medication? Prolonged use can cause dark concentrated urine. The medication is best absorbed when taken on an empty stomach. Take the medication with aluminum hydroxide to minimize GI upset. Drinking alcohol daily can cause drug-induced hepatitis To minimize the side effects of the vincristine (Oncovin) that a client is receiving, what does the nurse expect the dietary plan to include? Low in fat High in iron High in fluids Low in residue A postoperative client says to the nurse, "My neighbor, I mean the person in the next room, sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation? Tell the neighboring client to stop singing. Close the doors to both clients' rooms at night. Give the complaining client the prescribed as needed sedative. Move the neighboring client to a room at the end of the hall The nurse is providing postoperative care to a client who had a submucosal resection (SMR) for a deviated septum. The nurse should monitor for what complication associated with this type of surgery? Occipital headache Periorbital crepitus Expectoration of blood Changes in vocalization 16. A nurse is reviewing a plan of care for a client who was admitted with dehydration as a result of prolonged watery diarrhea. Which prescription should the nurse question? Oral psyllium (Metamucil) Oral potassium supplement Parenteral half normal saline Parenteral albumin (Albuminar) A client is to have mafenide (Sulfamylon) cream applied to burned areas. For which serious side effect of mafenide therapy should the nurse monitor this client? Curling ulcer Renal shutdown Metabolic acidosis Hemolysis of red blood cells A nurse is preparing to administer an ophthalmic medication to a client. What techniques should the nurse use for this procedure? Select all that apply. Clean the eyelid and eyelashes. Place the dropper against the eyelid. Apply clean gloves before beginning of procedure. Instill the solution directly onto cornea. Press on the nasolacrimal duct after instilling the solution. 17. The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply. Orientation Capillary refill Pupillary response Respiratory rate Pulse and skin temperature Movement and sensation A client reaches the point of acceptance during the stages of dying. What response should the nurse expect the client to exhibit? Apathy Euphoria Detachment Emotionalism A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions? Anger Denial Bargaining Acceptance . 18. When a client files a lawsuit against a nurse for malpractice, the client must prove that there is a link between the harm suffered and actions performed by the nurse that were negligent. This is known as: Evidence Tort discovery Proximate cause Common cause Following a surgery on the neck, the client asks the nurse why the head of the bed is up so high. The nurse should tell the client that the high-Fowler position is preferred for what reason? To avoid strain on the incision To promote drainage of the wound To provide stimulation for the client To reduce edema at the operative site The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is the priority nursing intervention to assist the client with taking the medication? Contact the client's children and ask them to hire a private duty aide who will provide round-the-clock care. Develop a chart for the client, listing the times the medication should be taken. Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. Instruct the client and client's children to put medications in a weekly pill organizer The nurse expects a client with an elevated temperature to exhibit what indicators of pyrexia? Select all that apply. Dyspnea Flushed face Precordial pain Increased pulse rate Increased blood pressure The nurse should instruct a client with an ileal conduit to empty the collection device frequently because a full urine collection bag may: Force urine to back up into the kidneys. Suppress production of urine. Cause the device to pull away from the skin. Tear the ileal conduit IThe triage nurse in the emergency department receives four clients simultaneously. Which of the clients should the nurse determine can be treated last? Multipara in active labor Middle-aged woman with substernal chest pain Older adult male with a partially amputated finger Adolescent boy with an oxygen saturation of 91% 19. Health promotion efforts with the chronically ill client should include interventions related to primary prevention. What should this include? Encouraging daily physical exercise Performing yearly physical examinations Providing hypertension screening programs Teaching a person with diabetes how to prevent complications A nurse who is working on a medical-surgical unit receives a phone call requesting information about a client who has undergone surgery. The nurse observes that the client requested a do not publish (DNP) order on any information regarding condition or presence in the hospital. What is the best response by the nurse? "We have no record of that client on our unit. Thank you for calling." "The new privacy laws prevent me from providing any client information over the phone." "The client has requested that no information be given out. You'll need to call the client directly." "It is against the hospital's policy to provide you with any information regarding any of our clients." When being interviewed for a position as a registered professional nurse, the applicant is asked to identify an example of an intentional tort. What is the appropriate response? Negligence Malpractice Breach of duty False imprisonment 20. The nurse plans care for a client with a somatoform disorder based on the understanding that the disorder is: A physiological response to stress A conscious defense against anxiety An intentional attempt to gain attention An unconscious means of reducing stress . 21. A nurse is caring for a client diagnosed with methicillin-resistant Staphylococcus aureus (MRSA) in the urine. The health care provider orders an indwelling urinary catheter to be inserted. Which precaution should the nurse take during this procedure? Droplet precautions Reverse isolation Surgical asepsis Medical asepsis Catheter insertion requires the procedure to be performed under sterile technique. Droplet precautions are used with certain respiratory illnesses. Reverse isolation is used with clients who may be immunocompromised. Medical asepsis involves clean technique/gloving. . 22. A nurse is teaching an adolescent about type 1 diabetes and self-care. Which questions from the client indicate a need for additional teaching in the cognitive domain? Select all that apply. "What is diabetes?" "What will my friends think?" "How do I give myself an injection?" "Can you tell me how the glucose monitor works?" "How do I get the insulin from the vial into the syringe? Place each step of the nursing process in the order that it should be used. Obtain client's nursing history. State client's nursing needs. Identify goals for care. Develop a plan of care. Implement nursing interventions. 23. In what position should the nurse place a client recovering from general anesthesia? Supine Side-lying High Fowler Trendelenburg Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Difficulty in swallowing Increased sensitivity to heat Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli The spouse of a comatose client who has severe internal bleeding refuses to allow transfusions of whole blood because they are Jehovah's Witnesses. The client does not have a Durable Power of Attorney for Healthcare. What action should the nurse take? Institute the prescribed blood transfusion because the client's survival depends on volume replacement. Clarify the reason why the transfusion is necessary and explain the implications if there is no transfusion. Phone the health care provider for an administrative prescription to give the transfusion under these circumstances. Give the spouse a treatment refusal form to sign and notify the health care provider that a court order now can be sought 24. Twenty-four hours after a cesarean birth, a client elects to sign herself and her baby out of the hospital. Staff members are unable to contact her health care provider. The client arrives at the nursery and asks that her infant be given to her to take home. What is the most appropriate nursing action? Give the infant to the client and instruct her regarding the infant's care Explain to the client that she can leave, but her infant must remain in the hospital. Emphasize to the client that the infant is a minor and legally must remain until prescriptions are received. 25. A client reports fatigue and dyspnea and appears pale. The nurse questions the client about medications currently being taken. In light of the symptoms, which medication causes the nurse to be most concerned? Famotidine (Pepcid) Methyldopa (Aldomet) Ferrous sulfate (Feosol) Levothyroxine (Synthroid) 26. The nurse assesses a client's pulse and documents the strength of the pulse as 3+. The nurse understands that this indicates the pulse is: faint, barely detectable. slightly weak, palpable. normal. bounding. 27. A toddler screams and cries noisily after parental visits, disturbing all the other children. When the crying is particularly loud and prolonged, the nurse puts the crib in a separate room and closes the door. The toddler is left there until the crying ceases, a matter of 30 or 45 minutes. Legally, how should this behavior be interpreted? Limits had to be set to control the child's crying. The child had a right to remain in the room with the other children. The child had to be removed because the other children needed to be considered. Segregation of the child for more than half an hour was too long a period of time Legally, a person cannot be locked in a room (isolated) unless there is a threat of danger either to the self or to others. Limit setting in this situation is not warranted. This is a reaction to separation from the parent, which is common at this age. Crying, although irritating, will not harm the other children. A child should never be isolated 28. An older client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which interventions have specific gerontologic implications the nurse must consider? Select all that apply. Assessment of skin turgor Documentation of vital sign Assessment of intake and output Administration of antiemetic drugs Replacement of fluid and electrolytes What should the nurse consider when obtaining an informed consent from a 17-year-old adolescent? If the client is allowed to give consent The client cannot make informed decisions about health care. If the client is permitted to give voluntary consent when parents are not available. The client probably will be unable to choose between alternatives when asked to consent. 29. An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls what expected sensory losses associated with aging? Select all that apply. Difficulty in swallowing Diminished sensation of pain Heightened response to stimuli Impaired hearing of high-frequency sounds Increased ability to tolerate environmental heat A nurse receives a subpoena in a court case involving a child. The nurse is preparing to appear in court. In addition to the state Nurse Practice Act and the American Nursing Association (ANA) Code for Nurses, what else should the nurse review? Nursing's Social Policy Statement State law regarding protection of minors ANA Standards of Clinical Nursing Practice References regarding a child's right to consent A client is receiving albuterol (Proventil) to relieve severe asthma. For which clinical indicators should the nurse monitor the client? Select all that apply. Tremors Lethargy Palpitations Visual disturbances Decreased pulse rate 30. A client asks about the purpose of a pulse oximeter. The nurse explains that it is used to measure the: