HESI Fundamentals Exam
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 infection rate.
d.
Rate of needle-stick injuries by nurse.
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 of tongue
C.
Use a penlight to observe back of oral cavity
D.
Auscultate breath sounds after client swallows
3. The father of an 11-year-old boy….
inform the father that it is most important to let the son that nocturnal emissions are normal
4. 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
5. 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
6. 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 protein meals
B.
Engage in strenuous activity for an hour daily
C.
Keep a record of food and drinks consumed daily
D.
Participated in a group exercise class 3 times a week
7. 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
8. 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
9. 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 nurse implement?
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
10. 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
11. 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
12. 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
13. 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
14. 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 error report.
d.
Determine if the pain was relieved.
15. 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
16. 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
17. 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
18. 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
19. 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
20. 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 to take?
A.
Force oral fluids
B.
Request a nutrition consult
C.
Initiate contact precautions
D.
Limit visitors to immediate family only
21. 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
22. 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
23. 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
24. 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
25. 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
26. 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
back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which
response is best for the nurse to provide?
a.
Surgery removes the disk and is the only treatment that can totally resolve the pain
b.
The medication regimen you previously used should be re-evaluated for dose adjustment
c.
Massage and hot pack treatments are less invasive and can provide temporary relief
d.
Acupuncture is a complementary therapy that is often effective for management of pain
27. The nurse is providing wound care to a client with stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription
states “clean the wound and then apply collagenase.” collagenase is a debriding agent. The prescription does not specify a cleaning method.
Which technique should the nurse cleanse the pressure ulcer?
a.
Lightly coat the wound with povidone-iodine solution
b.
Irrigate the wound with sterile normal saline
c.
Flush the wound with sterile hydrogen peroxide
d.
Remove the eschar with a wet-to-dry dressing
28. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
a.
Document the client’s circadian rhythms
b.
Assess for flushed, warm skin regularly
c.
Measure temperature at regular intervals
d.
Vary sites for temperature measurement
29. When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first?
a.
Position the client supine for a few minutes
b.
Assist the client to stand at the bedside
c.
Apply the blood pressure cuff securely
d.
Record the client’s pulse rate and rhythm
30. The nurse retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving
hydromorphone 3 mg IM 6 hours PRN severe pain. How many mL should the nurse administer to the client? (Enter the numerical value
only. If rounding is required , round to the nearest tenth) Ans: 0.8
31. The unlicensed assistive personnel (UAP) describes the appearance of the bowel movement of several clients. Which description
warrants additional follow up by the nurse? (select all that applies).
a. Solid with red streaks.
b. Brown liquid.
c. Multiple hard pellets.
d. Formed but soft.
e. Tarry appearance.
32. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The
UAP requests a change in assignment...she has not yet been fitted for a particulate filter mask.Which action should the nurse take?
a.
Advise the UAP to wear a standard face mask to take vital signs, and then get fitted for a filter mask before
providing personal care
b.
Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client
c.
Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client
d.
Before changing assignments, determine which staff members have fitted particulate filter masks
33. In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative nurse is arranging for discharge, the client
verbalizes concerns about pain. What action should the nurse implement?
a.
Explain the respiratory problems that can occur with morphine use.
b.
Teach family how to evaluate the effectiveness of analgesics.
c.
Recommend asking the healthcare professional for a patient-controlled analgesic (PCA) pump.
d.
Provide client with a schedule of around-the-clock prescribed analgesic use.
34. What assessment finding places a client at risk for problems associated with impaired skin integrity?
a.
Scattered macula of the face
b.
Capillary refill 5 seconds
c.
Smooth nail texture
d.
Absence of skin tenting
35. When evaluating the effectiveness of a client’s nursing care, the nurse first reviews the expected outcomes identified in the plan of care.
What action should the nurse take next?
a.
Determine if the expected outcomes were realistic
b.
Obtain current client data to compare with expected outcomes
c.
Modify the nursing interventions to achieve the client’s goals
d.
Review related professional standards of care
36. The nurse attaches a pulse oximeter to a client’s fingers and obtains an oxygen saturation reading of 91%. Which assessment finding
most likely contributes to this reading?
a.
BP 142/88 mmHg
b.
2+ edema of fingers and hands
c.
Radial pulse volume is +3
d.
Capillary refill time is 2 seconds
37. The nurse is caring for a hospitalized client who was placed in restraints due to confusion. The family removes the restraints while they
are with the client. When the family leaves, what action should the nurse take first?
a.
Apply the restraints to maintain the client’s safety.
b.
Reassess the client to determine the need for continuing restraints.
c.
Document the time the family left and continue to monitor the client.
d.
Call the healthcare provider for a new prescription.
38. The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the
prescribed medications, the client appears anxious. What action is most important for the nurse to implement?
a.
Instruct the client to repeat the medication plan
b.
Encourage client to take a PRN antianxiety drug
c.
Provide written instructions that are easy to follow
d.
Include a family member in the teaching session
39. What instruction should the nurse provide for an UAP caring for a client with MRSA who has a prescription for contact precautions?
a.
Do not allow visitors until precautions are discontinued
b.
Wear sterile gloves when handling the client’s body fluid
c.
Have the client wear a mask whenever someone enters the room
d.
Don a gown and gloves when entering the return
40. While suctioning a client’s nasopharynx the nurse observes that the client’s oxygen saturation remains at 94% which is the same reading
obtained prior to starting the procedure. What action should the nurse take in response to this finding?
a.
Complete the intermittent suction of the nasopharynx.
b.
Reposition the pulse oximeter clip to obtain a new reading.
c.
Stop suctioning until the pulse oximeter reading is above 95%.
d.
Apply an oxygen mask over the client’s nose and mouth
41. UAP has lowered the head of the bed to change the lines for a client who is bedless. Which observation...most immediate intervention
by the nurse?
a.
A feeding is infusing at 40 mL/hr through an enteral feeding tube
b.
The urine meter attached to the urinary drainage bag is completely full
c.
There is a large dependent loop in the client’s urinary drainage tubing
d.
Purulent drainage is present around the insertion site of the feeding tube
42. A male client presents to the clinics stating that he has a high stress job and is having difficulty falling asleep at night. .The client reports
having a constant headache and is seeking medication to help the sleep. Which intervention should the nurse implement?
a.
Determine the client’s sleep and activity pattern
b.
Obtain prescription for client to take when stressed
c.
Refer client for a sleep study and neurological follow-up
d.
Teach coping strategies to use when feeling stressed
43. The nurse is teaching a client about use of the syringes and needles for home administration of medications. Which action by the client
indicates an understanding of standard precaution?
a.
Remove needle before discarding used syringes
b.
Wear gloves to dispose of the needle and syringe
c.
Done a face mask before administering the medication
d.
Washes hands before handling the needle and syringe
44. The nurse observes an UAP positioning a newly admitted client who has a seizure disorder. The client is supine and the UAP is placing
soft pillows along the side rails. Which action should the nurse implement?
a.
Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
b.
Ensure that the UAP has placed pillows effectively to protect the client
c.
Ask the UAP to use some pillows to prop the client in a side-lying position
d.
Assume responsibility for placing the pillows while the UAP complete another task
45. A cerebrovascular accident is placed on a ventilator. The client’s daughter arrives with a durable power of attorney, and a living will that
indicates the...extraordinary life saving measures. What action should the nurse take?
a.
Refer to the risk manager
b.
Notify the healthcare provider
c.
Discontinue the ventilator
d.
Review the medical record
46. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway
outside her room. What is the best action?
a.
Ask the family to wait in the cafeteria when the next of kin makes the necessary arrangements
b.
Provide space and privacy for the family to share their concerns about the client’s discharge
c.
Ask the social worker to encourage the family to clear the hallway
d.
Explain to the family the client’s need for privacy so that she can make independent decisions
47. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most
important for the nurse to obtain when planning care?
a.
Amount of support provided by family members
b.
Measurement of pain using a scale of 0 to 10
c.
The ability to perform ADLs
d.
Nonverbal behaviors exhibited when pain occurs
48. A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that the chronic
constipation and had not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important
for the nurse to implement?
a.
Evaluate the stool samples for presence of blood
b.
Assess for the presence of an impaction
c.
Determine what home remedies were used
d.
Obtain list of prescribed home medication
49. Which assessment data reflects the need for the nurses to include the problem, “Risk for falls” in a client’s plan of care?
a.
Recent serum hemoglobin level of 16g/dL
b.
Opioid analgesic received one hour ago
c.
Stooped posture with a steady gait
d.
Expressed feelings of depression
50. The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL, for the previous 6 hour shift.
Which intervention should the nurse implement first?
a.
Check the drainage tubing for a kink
b.
Review the intake and output record
c.
Notify the healthcare provider
d.
Give the client 8 oz of water to drink
51. The nurse is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby
by C-section in the next 24 hours. What should the nurse include in the assessment?
a.
Provider an interpreter to convey the meaning of words and messages in translation
b.
Commend the client for her patience after a long wait in the admission process
c.
Arrange for the hospital chaplain to visit the client during her hospital stay
d.
Rely on cultural norms as the basis for providing nursing care for this client
52. During the admission assessment of a terminally ill male client that he is an agnostic. What is the best nursing action in response to this
statement?
a.
Provide information about the hours and location of the chapel
b.
Document the statement of the client’s spiritual assessment
c.
Invite the client to a healing service for people of all religions
d.
Offer to contact a spiritual advisor of the client’s choice
53. The nurse is reviewing the signed operative consent with a client who is admitted for the removal of a lipoma on the left leg. The client
states that the permit should include…
A.
Notify the OR staff of the client’s confusion
B.
Have the client sign a new surgical permit
C.
Add the additional information to the permit
D.
Inform the surgeon about the client’s concern
54. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get
out of the room because her husband is too ill to get out of bed.
A.
Administer nasal oxygen at a rate of 5 L/min
B.
Help the client to lie back down in the bed
C.
Quickly pivot the client to the chair and elevate the legs
D.
Check the client’s blood pressure and pulse deficit
55. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the
nurse take
a.
divert the client’s attention
b.
Call for additional help from staff
c.
Document the planned action
d.
Re-assess the client situation