1
HESI FUNDAMENTALS ALL EXAM TESTBANK WITH
QUESTIONS AND VERIFIED CORRECT ANSWERS
[RATIONALES PROVIDED]
The health care provider has changed a client's prescription from the PO to the IV
route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication?
A. The client will experience increased tolerance to the drug's effects and
may need a higher dose.
B. The onset of action of the drug will occur more rapidly, resulting in a more rapid
effect.
C. The medication will be more highly protein-bound, increasing the duration of
action.
D. The therapeutic index will be increased, placing the client at greater risk for
toxicity. - Answer: B
Because the absorptive process is eliminated when medications are administered
via the IV route, the onset of action is more rapid, resulting in a more immediate
effect (B). Drug tolerance (A), protein binding (C), and the drug's therapeutic index
(D) are not affected by the change in route from PO to IV. In addition, an increased
therapeutic index reduces the risk of drug toxicity.
A male client is laughing at a television program with his wife when the evening
nurse enters the room. He says his foot is hurting and he would like a pain pill.
How should the nurse respond?
A. Ask him to rate his pain on a scale of 1 to 10.
B. Encourage him to wait until bedtime so the pill can help him sleep.
C. Attend to an acutely ill client's needs first because this client is laughing.
D. Instruct him in the use of deep breathing exercises for pain control. - Answer:
A
Obtaining a subjective estimate of the pain experience by asking the client to rate
his pain
(A) helps the nurse determine which pain medication should be administered and
also provides a baseline for evaluating the effectiveness of the medication.
Medicating for pain should not be delayed so that it can be used as a sleep
medication (B). (C) is judgmental.
(D) should be used as an adjunct to pain medication, not instead of medication.
,2
The nurse determines that a postoperative client's respiratory rate has increased
from 18 to 24 breaths/min. Based on this assessment finding, which intervention
is most important for the nurse to implement?
A. Encourage the client to increase ambulation in the room.
B. Offer the client a high-carbohydrate snack for energy.
C. Force fluids to thin the client's pulmonary secretions.
D. Determine if pain is causing the client's tachypnea. - Answer: D
Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause
tachypnea (increased respiratory rate). Encouraging (A) when the respiratory rate
is rising above normal limits puts the client at risk for further oxygen
desaturation. (B) can increase the client's carbon metabolism, so an alternative
source of energy, such as Pulmocare liquid supplement, should be offered
instead. (C) could increase respiratory congestion in a client with a poorly
functioning cardiopulmonary system, placing the client at risk of fluid overload.
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.
- Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first (D), respecting any personal beliefs such as cultural
or spiritual values. After client teaching, the client may still choose (A or B).
Brochures reinforce the teaching (C).
Based on the nursing diagnosis of Risk for infection, which intervention is
best for the nurse to implement when providing care for an older
incontinent client? A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers. - Answer: A
The best action to decrease the risk of infection in vulnerable clients is hand
washing (A).
,3
(B) is not necessary unless the client has an infection. (C) increases the risk of
infection. (D) does not reduce the risk of infection.
, 4
The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the
count for a second 30-second interval, the nurse counts eight respirations. Which
respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28 - Answer: B
The most accurate respiratory rate is the second count obtained by the nurse,
which was not interrupted by coughing. Because it was counted for 30 seconds,
the rate should be doubled (B). (A, C, and D) are inaccurate recordings.
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's position.
B. Help the patient 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.
-
Answer: A, D
(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).
During a routine assessment, an obese 50-year-old female client expresses
concern about her sexual relationship with her husband. Which is the best
response by the nurse? A. Reassure the client that many obese people have
concerns about sex.
B. Remind the client that sexual relationships need not be affected by obesity.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns. - Answer: D
(D) provides an opportunity for the client to verbalize her concerns and provides
HESI FUNDAMENTALS ALL EXAM TESTBANK WITH
QUESTIONS AND VERIFIED CORRECT ANSWERS
[RATIONALES PROVIDED]
The health care provider has changed a client's prescription from the PO to the IV
route of administration. The nurse should anticipate which change in the
pharmacokinetic properties of the medication?
A. The client will experience increased tolerance to the drug's effects and
may need a higher dose.
B. The onset of action of the drug will occur more rapidly, resulting in a more rapid
effect.
C. The medication will be more highly protein-bound, increasing the duration of
action.
D. The therapeutic index will be increased, placing the client at greater risk for
toxicity. - Answer: B
Because the absorptive process is eliminated when medications are administered
via the IV route, the onset of action is more rapid, resulting in a more immediate
effect (B). Drug tolerance (A), protein binding (C), and the drug's therapeutic index
(D) are not affected by the change in route from PO to IV. In addition, an increased
therapeutic index reduces the risk of drug toxicity.
A male client is laughing at a television program with his wife when the evening
nurse enters the room. He says his foot is hurting and he would like a pain pill.
How should the nurse respond?
A. Ask him to rate his pain on a scale of 1 to 10.
B. Encourage him to wait until bedtime so the pill can help him sleep.
C. Attend to an acutely ill client's needs first because this client is laughing.
D. Instruct him in the use of deep breathing exercises for pain control. - Answer:
A
Obtaining a subjective estimate of the pain experience by asking the client to rate
his pain
(A) helps the nurse determine which pain medication should be administered and
also provides a baseline for evaluating the effectiveness of the medication.
Medicating for pain should not be delayed so that it can be used as a sleep
medication (B). (C) is judgmental.
(D) should be used as an adjunct to pain medication, not instead of medication.
,2
The nurse determines that a postoperative client's respiratory rate has increased
from 18 to 24 breaths/min. Based on this assessment finding, which intervention
is most important for the nurse to implement?
A. Encourage the client to increase ambulation in the room.
B. Offer the client a high-carbohydrate snack for energy.
C. Force fluids to thin the client's pulmonary secretions.
D. Determine if pain is causing the client's tachypnea. - Answer: D
Pain, anxiety, and increasing fluid accumulation in the lungs (D) can cause
tachypnea (increased respiratory rate). Encouraging (A) when the respiratory rate
is rising above normal limits puts the client at risk for further oxygen
desaturation. (B) can increase the client's carbon metabolism, so an alternative
source of energy, such as Pulmocare liquid supplement, should be offered
instead. (C) could increase respiratory congestion in a client with a poorly
functioning cardiopulmonary system, placing the client at risk of fluid overload.
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.
- Answer: D
Because a shower is most beneficial for the client in terms of hygiene, the client
should receive teaching first (D), respecting any personal beliefs such as cultural
or spiritual values. After client teaching, the client may still choose (A or B).
Brochures reinforce the teaching (C).
Based on the nursing diagnosis of Risk for infection, which intervention is
best for the nurse to implement when providing care for an older
incontinent client? A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct client in the use of adult diapers. - Answer: A
The best action to decrease the risk of infection in vulnerable clients is hand
washing (A).
,3
(B) is not necessary unless the client has an infection. (C) increases the risk of
infection. (D) does not reduce the risk of infection.
, 4
The nurse is counting a client's respiratory rate. During a 30-second interval, the
nurse counts six respirations and the client coughs three times. In repeating the
count for a second 30-second interval, the nurse counts eight respirations. Which
respiratory rate should the nurse document?
A. 14
B. 16
C. 17
D. 28 - Answer: B
The most accurate respiratory rate is the second count obtained by the nurse,
which was not interrupted by coughing. Because it was counted for 30 seconds,
the rate should be doubled (B). (A, C, and D) are inaccurate recordings.
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's position.
B. Help the patient 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.
-
Answer: A, D
(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).
During a routine assessment, an obese 50-year-old female client expresses
concern about her sexual relationship with her husband. Which is the best
response by the nurse? A. Reassure the client that many obese people have
concerns about sex.
B. Remind the client that sexual relationships need not be affected by obesity.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns. - Answer: D
(D) provides an opportunity for the client to verbalize her concerns and provides
