HESI Fundamentals

1. A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved. a. Number of staff induced injury b. Client satisfaction survey c. Health care-associated infectionrate. d. Rate of needle-stick injuries bynurse. 2. The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client...the client’s gag reflex. Which action should the nurse include? A. Offer smalls sips of water through a straw B. Place tongue blade on back half oftongue C. Use a penlight to observe back of oral cavity D. Auscultate breath sounds after client swallows 3. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. A. Assess the client for confusion and reteach the procedure B. Check the urine for color and texture C. Empty the urinal contents into the 24-hour collection container D. Discard the contents of the urinal 4. A 54-year-old male client and his wife were informed this morning that he has terminal cancer. Which nursing intervention is likely to be most A. Ask her how she would like to participate in the client’s care B. Provide the wife with information about hospice C. Encourage the wife to visit after painful treatments are completed D. Refer her to support group for family members of those dying of cancer 5. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend? A. Plan low carbohydrate and high proteinmeals B. Engage in strenuous activity for an hourdaily C. Keep a record of food and drinks consumed daily D. Participated in a group exercise class 3 times a week 6. The nurse assesses a client who has a nasal cannula delivering oxygen at 2 L/min. To assess for skin damage related to the cannula, which areas should the nurse observe? A. Tops of the ear B. Bridge of the nose C. Around the nostrils D. Over the cheeks E. Across the forehead 7. The nurse observes an unlicensed assistive personnel (UAP) who is providing a total bed bath for a confused and lethargic client. The UAP is soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take? a. Remove the basin of water from the client’s bed immediately b. Remind the UAP to dry between the client’s toes completely c. Advise the UAP that this procedure is damaging to the skin d. Add skin cream to the basin of water while the foot is soaking 8. The nurse in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the nurseimplement? a. Communicate the colleague’s actions to the unit charge nurse b. Send an email to facility administration reporting the action c. Write an anonymous complaint to a professional website d. Post a comment about the action on a staff discussion board 9. At 0100 on a male client’s second postoperative night, the client states he is unstable to sleep and plans to read until feeling sleepy. What action should the nurse implement? a. Leave the room and close the door to the client’s room b. Assess the appearance of the client’s surgical dressing c. Bring the client a prescribed PRN sedative-hypnotic d. Discuss symptoms of sleep deprivation with the client 10. The nursing staff in the cardiovascular intensive care unit are creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy? a. Remove identifying information of the clients who participated b. Recall that authored content may be legally discoverable c. Share material from credible, peer reviewed sources only d. Respect all copyright laws when adding website content 11. A male client with unstable angina needs a cardiac catheterization, so the healthcare provider explains the risks and benefits of the procedure, and then leaves to set up for the procedure. When the nurse presents the consent form for signature, the client hesitates and asks how the wires will keep his heart going. Which action should the nurse take? a. Answer the client’s specific questions with a short understandable explanation b. Postpone the procedure until the client understands the risks and benefits c. Call the client’s next of kin and ask them to provide verbal consent d. Page the healthcare provider to return and provide additional explanation 12. The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform? a. Tilt the pelvis forwards and backwards b. bend the arm by flexing the ulnar to the humerus c. Turn the head to the right and left d. Extend the arm at the ide and rotate in circles 13. A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first? a. Access for side effects of the medication. b. Document the client’s responses. c. complete a medication errorreport. d. Determine if the pain wasrelieved. 14. When assessing a male client, the nurse finds that he is fatigue, and is experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which? a. Hyperphosphatemia b. Hypocalcemia c. Hypermagnesemia d. Hypokalemia 15. A female client’s significant other has been at her bedside providing reassurances and support for the past 3days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement? a. Obtain a perception from the healthcare provider regarding visitation privileges b. Request a consultation with the ethics committee for resolution of the situation c. Encourage the client to speak with her husband regarding his disruptive behavior d. Communicate the client’s wishes to all members of the multidisciplinary team 16. When measuring vital signs, the nurse observes that a client is using accessory neck muscles during respirations. What follow-up action should the nurse take first? a. Determine pulse pressure b. Auscultate heart sounds c. Measure oxygen saturation d. Check for neck vein distention 17. To avoid nerve injury, what location should the nurse select to administer a 3 mL IM injection? a. Ventrogluteal b. outer upper quadrant of the buttock c. Two inches below the acromion process d. Vastus lateralis 18. Which instruction should the nurse include in the discharge teaching plan for an adult client with hypernatremia? a. Monitor daily urine output volume b. Drink plenty of water whenever thirsty c. Use salt tablets for sodium content d. Review food labels for sodium content 19. While changing a client’s post operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse totake? A. Force oral fluids B. Request a nutrition consult C. Initiate contact precautions D. Limit visitors to immediate family only 20. To prepare a client for the potential side effects of a newly prescribed medication, what action should the nurse implement? a. Assess the client for health alterations that may be impacted by the effects of the medication b. Teach the client how to administer the medication to promote the best absorption c. Administer a half dose and observe the client for side effects before administering a full dosage d. Encourage the client to drink plenty of fluids to promote effective drug distribution 21. A client is 2 days post-op from a thoracic surgery and is complaining of incisional pain. The client last received pain medication 2 hours ago. He is rating his pain a 5 on a 1-10 scale. After calling the provider, what is the nurse's next action? a. instruct the client to use guided imagery and slow rhythmic breathing b. Provide at least 20 minutes of back massage and gentle effleurage c. Encourage the client to watch TV. d. Place a hot water circulation device, such as an Aqua K pad, to operative site 22. A client with cirrhosis and ascites is receiving furosemide 40 mg BID. The pharmacy provides 20 mg tablets. How many tablets should the client receive each day? [Enter numeric value only] 4 tablets 23. An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper and skin breakdown is obvious over his sacral area. What action should the nurse implement first? a. Establish a toileting schedule to decrease episodes of incontinence b. Complete a functional assessment of the client’s self-care abilities c. Apply a barrier ointment to intact areas that may be exposed to moisture d. Determine the size and depth of skin breakdown over the sacral area 24. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview? a. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record b. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace c. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically d. Completing the electronic record during an interview is a legal obligation of the examining nurse 25. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regime. The client tells the nurse that she does not want to have