HESI Fundamentals Practice Exam #1
A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that
she's ready to go home to die. What intervention should the nurse initiate? - (correct Answer) - Evaluate
the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the
HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not
necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure.
Which laboratory test indicates client's protein status for the longest length of time? - (correct Answer) -
Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance with bathing? - (correct
Answer) - "I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces? - (correct Answer) - Place the
soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest priority? - (correct Answer) -
Impaired gas exchange
The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his
temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet
sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing
action is most important for the nurse to implement? - (correct Answer) - Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring.
The home health nurse visits an elderly female client who had a brain attack 3 months ago & is now able
to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications
for this client's care? - (correct Answer) - The nurse notes there are numerous scatter rugs throughout
the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter & 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? - (correct Answer) - One-inch pressure sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx? -
(correct Answer) - 0800, 1200, 1600, 2000
, The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to tolerate
a higher level of pain? - (correct Answer) - 1 55y/o woman who has had moderate low back pain for 3
months
Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for
the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to
relieve the pain. All other clients are having new experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt to have
my tonsils & adenoids taken out?" Which response is best for the nurse to provide? - (correct Answer) -
"It may hurt, but we'll give you medicine to help you feel better."
A low-sodium, low-protein diet is prescribed for a 45y/o client with renal insufficiency & HTN, who
gained 3lbs in the last month. The nurse determines that the client has been noncompliant with the diet,
based on which report from the 24hr diet recall? - (correct Answer) - 1. Snack of potato chips & diet soda
2. Lunch of tuna, carrots, fruit & coffee
3. Breakfast of eggs, bacon, toast & coffee
4. Bedtime snack of crackers & milk
What intervention should the nurse include in the care plan for a client who is being treated with an
Unna's paste boot for leg ulcers due to chronic venous insufficiency? - (correct Answer) - Check capillary
refill of toes on lower extremity with Unna's paste boot
Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation.
No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a
sterile dressing & should not be removed q8h. Weekly removal is reasonable.
Male client with nursing diagnosis of "spiritual distress". What intervention is best for the nurse to
implement when caring for this client? - (correct Answer) - Use reflective listening techniques when the
client expresses spiritual doubts.
Rationale: Client should be consulted before involving chaplain.
Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to impending death." What
intervention is best for the nurse to implement when caring for this client? - (correct Answer) - Assist &
support the client in establishing short-term goals.
A 35y/o client with cancer refuses to allow a nurse to insert an IV for scheduled chemo & states that
she's ready to go home to die. What intervention should the nurse initiate? - (correct Answer) - Evaluate
the client's mental status for competence to refuse treatment
Rationale: Competent clients have the right to refuse treatment. The nurse cannot document until the
HCP is notified of the patient's wishes & a d/c RX is obtained. Advance directives & DNR are not
necessary for competent client to refuse care.
A client with chronic renal disease is admitted to the hospital for evaluation prior to a surgical procedure.
Which laboratory test indicates client's protein status for the longest length of time? - (correct Answer) -
Serum albumin
Rationale: Serum albumin has a long half-life.
What client statement indicates to the nurse that the client requires assistance with bathing? - (correct
Answer) - "I don't understand why I'm so weak & tired."
How should the nurse handle linens that are soiled with incontinent feces? - (correct Answer) - Place the
soiled linens in a pillow case & deposit them in the dirty linen hamper
When caring for an immobile client, what nursing diagnosis has the highest priority? - (correct Answer) -
Impaired gas exchange
The nurse assesses an immobile, elderly male client & determines that his blood pressure is 138/60, his
temperature is 95.8F & his output is 100 mL of concentrated urine during the last hour. He has wet
sounding lungs & increased respiratory secretions. Based on these assessment findings , what nursing
action is most important for the nurse to implement? - (correct Answer) - Turn the client q2h
Rationale: It will help move & drain respiratory secretions & prevent pneumonia from occurring.
The home health nurse visits an elderly female client who had a brain attack 3 months ago & is now able
to ambulate with the assistance of a quad cane. Which assessment finding has the greatest implications
for this client's care? - (correct Answer) - The nurse notes there are numerous scatter rugs throughout
the house
The nurse removes the dressing on a client's heel that is cover a pressure sore 1" in diameter & 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? - (correct Answer) - One-inch pressure sore draining serous fluid
Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx? -
(correct Answer) - 0800, 1200, 1600, 2000
, The nurse working in the ED is assessing 4 clients' ability to tolerate pain. Which client is likely to tolerate
a higher level of pain? - (correct Answer) - 1 55y/o woman who has had moderate low back pain for 3
months
Rationale: Experiences with the same type of pain that has successfully been relieved makes it easier for
the client to interpret the pain sensation and, as a result, the client is better prepared to take steps to
relieve the pain. All other clients are having new experiences with pain.
A 4y/o boy who is scheduled for a tonsillectomy & adenoidectomy asks the nurse, "Will it hurt to have
my tonsils & adenoids taken out?" Which response is best for the nurse to provide? - (correct Answer) -
"It may hurt, but we'll give you medicine to help you feel better."
A low-sodium, low-protein diet is prescribed for a 45y/o client with renal insufficiency & HTN, who
gained 3lbs in the last month. The nurse determines that the client has been noncompliant with the diet,
based on which report from the 24hr diet recall? - (correct Answer) - 1. Snack of potato chips & diet soda
2. Lunch of tuna, carrots, fruit & coffee
3. Breakfast of eggs, bacon, toast & coffee
4. Bedtime snack of crackers & milk
What intervention should the nurse include in the care plan for a client who is being treated with an
Unna's paste boot for leg ulcers due to chronic venous insufficiency? - (correct Answer) - Check capillary
refill of toes on lower extremity with Unna's paste boot
Rationale: Boot becomes rigid after it dries, so it is important to check distally for adequate circulation.
No bandage should be put under it. Should be applied from foot & wrapped towards knee. Acts as a
sterile dressing & should not be removed q8h. Weekly removal is reasonable.
Male client with nursing diagnosis of "spiritual distress". What intervention is best for the nurse to
implement when caring for this client? - (correct Answer) - Use reflective listening techniques when the
client expresses spiritual doubts.
Rationale: Client should be consulted before involving chaplain.
Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to impending death." What
intervention is best for the nurse to implement when caring for this client? - (correct Answer) - Assist &
support the client in establishing short-term goals.
