HESI Fundamentals Exam Verified Questions and Answers| 2021 100% correct HESI Fundamental of Nursing ( Basics of Nursing Practice)
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HESI Fundamental of Nursing ( Basics of Nursing Practice)
HESI Fundamentals Exam Verified Questions and Answers| 2021 100% correct HESI Fundamental of Nursing ( Basics of Nursing Practice)
HESI Fundamentals Exam Verified Questions and Answers| 2021 100% correct HESI Fundamental of Nursing ( Basic...
Fundamental of Nursing ( Basics of Nursing Practice)
1- An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is
always angry at me." The nurse's best initial response is "Your parent is:
Working through acceptance of the situation."
2- During the beginning phase of a therapeutic relationship, a clear understanding of participants' roles is
important because the client:
Needs to know what to expect from the relationship
3- The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be
affected by aging?
Strategies to handle stress
4- What is the primary purpose of evidence-based nursing (EBP)?
Using results from research to improve the outcome of nursing care
5- A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the
rationale for a high-protein diet is to
Promote cell growth and bone union
6- Nursing actions for the older adult should include health education and promotion of self-care. Which is
most important when working with the older adult client?
Reinforcing the client's strengths and promoting reminiscing
7- A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more
obvious on inspiration. This assessment should be documented as:
Crackles
8- A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population. One
of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from bringing all that
"home medicine stuff" to their family members. Which response by the recently hired nurse is most appropriate?
You are right because they may have a negative impact on people's health.
9- During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and other
physical characteristics are within the expected range. The nurse records these findings on the clinical record.
Legally, how should the nurse's action be interpreted?
The nurse met the requirements set forth in the Nurse Practice Act.
10- Which of the following legal defenses is the most important for a nurse to develop?
Accountability
11- A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers
that the client has received burns due to incorrect settings when the heating pad was initiated. Which principle would
legally apply?
The nurse could be held liable for the injury that occurred
12- The plan of care for the client was to lose 7 pounds by the end of the month. The client only lost 3 pounds.
The nurse should:
Reevaluate the plan of care for appropriateness.
13- When caring for a client with venous insufficiency, the nurse would implement which nursing measure?
Elevate the client's legs above heart level.
14- A nurse is teaching a client about gentamycin (Garamycin) that has been prescribed for a severe infection.
Which statement indicates to the nurse that the client needs further teaching?
It is okay for me to stop taking this medication after a few days."\
15- A nurse is assigned to change a central line dressing. The agency policy is to clean the site with Betadine
and then cleanse with alcohol. The nurse recently attended a conference that presented information that alcohol
should precede Betadine in a dressing change. In addition, an article in a nursing journal stated that a new product
was a more effective antibacterial than alcohol and Betadine. The nurse has a sample of the new product. How
should the nurse proceed?
Follow the agency's policy unless it is contradicted by a health care provider's prescription.
16- While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in
blood pressure. The nurse would report this finding as:
Orthostatic hypotension
17- A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that a
hematoma is developing, edema is present and that the client reports tenderness when the ankle is palpated. The
nurse anticipates that the plan of care will include the application of a(n):
Ice bag
,18- The professional obligation of a nurse to assume responsibility for actions is referred to as:
Accountability
19- The nurse prepares to give a prescribed capsule of hydroxyzine (Vistaril) to a client. The client begins to
vomit so the nurse holds the oral medication. The nurse has not opened the medication package. Proper and safe
disposal of the capsule of hydroxyzine requires the nurse to:
Return the capsule to the pharmacy
20- When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent
what serious complication?
Aspiration pneumonia
21- The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse
should monitor the results of which laboratory test to evaluate the client for hypoxia?
Arterial blood gas
22- A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital. When
formulating the plan of care for this client, the nurse should include that the client is at risk for:
Falls
23- A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood testing
has been prescribed when there is no history of health problems. What is an appropriate nursing response?
"It is performed routinely starting at your age as part of an assessment for colon cancer
24- An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my parent is
always angry at me." The nurse's best initial response is "Your parent is:
working through acceptance of the situation."
25- A health care provider tells a client about the diagnosis of inoperable cancer and that the client does not
have long to live. After the health care provider leaves, the client says to the nurse, "I feel fine. I probably only have
the flu." The nurse determines that the client is in the denial stage of grief. What should the nurse do to help meet the
client's emotional needs?
Allow the denial and be available to discuss the situation with the client.
26- The nurse has provided instructions about back safety to a client. Which client statement indicates
understanding of the instructions?
"I should carry objects close to my body."
27- The nurse teaching a health awareness class identifies which situation as being the highest risk factor for
the development of a deep vein thrombosis (DVT)?
Inactivity
28- A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse should
assign the client to which type of room?
Negative airflow room
29- A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan?
Effectiveness of the interventions
30- A nurse who promotes freedom of choice for clients in decision-making best supports which principle?
Autonomy
31- The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the
blood has what effect on oxygenation status?
A low hemoglobin level causes reduced oxygen-carrying capacity.
32- A client with hypothermia is brought to the emergency department. What treatment does the nurse
anticipate?
Core rewarming with warm fluids
33- A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol
recovery program." How should the nurse respond?
Do not allow the sponsor to review the record.
34- Two nurses are planning to help a client with one-sided weakness to move up in bed. What should the
nurses do to conform to a basic principle of body mechanics?
Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the client, turn toward
the head of the bed, and then move the client.
35- In all states of the United States, what is the professional nurse's legal responsibility regarding child abuse?
Report any suspected abuse to local law enforcement authorities.
36- The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The nurse
draws up the prescribed dose and then requests that another nurse witness wasting of the remaining medication. The
, second nurse states that there is no time to observe the wasting of the medication, enters the identification to serve as
the witness, and leaves the area. What is the appropriate action for the first nurse to take?
Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the medication.
37- Nursing actions for the older adult should include health education and promotion of self-care. Which is
most important when working with the older adult client?
Reinforcing the client's strengths and promoting reminiscing
38- The nurse is caring for a surgical client that develops a wound infection during hospitalization. How is this
type of infection classified?
Nosocomial
39- A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse discovers
that the client has received burns due to incorrect settings when the heating pad was initiated. Which principle would
legally apply?
The nurse could be held liable for the injury that occurred
40- A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the
illness. Behaviors that indicate the client is emotionally accepting of impending death are that the client is:
Revising the client's will and planning a visit to a friend
41- A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and
oxygen. The child's temperature increased until it reached 103° F. When notified, the health care provider
determined that there was no need to change treatment, even though the child had a history of febrile seizures.
Although concerned, the nurse took no further action. Later, the child had a seizure that resulted in neurologic
impairment. Legally, who is responsible for the child's injury?
Nurse, because failure to further question the health care provider about the child's status placed the child at risk
42- The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin in the
blood has what effect on oxygenation status?
A low hemoglobin level causes reduced oxygen-carrying capacity.
43- The nurse is providing post-procedure care for a client that had a central venous access device (CVAD)
inserted. Before the CVAD is used, what procedure is performed to verify placement?
Chest x-ray
44- When caring for a client who is receiving enteral feedings, the nurse should take which measure to prevent
aspiration?
Elevate the head of the bed between 30 and 45 degrees.
45- A nurse is teaching a client how to use the call bell/call light system. Which level of Maslow's Hierarchy of
Needs does this nursing action address?
Safety
46- A nurse is teaching a parenting class. What should the nurse suggest about managing the behavior of a
young school-age child?
Be consistent about established rules.
47- A client with internal bleeding is in the intensive care unit (ICU) for observation. At the change of shift an
alarm sounds, indicating a decrease in blood pressure. What is the initial nursing action?
Perform an assessment of the client before resuming the change-of-shift report.
48- The nurse is caring for a surgical client that develops a wound infection during hospitalization. How is this
type of infection classified?
Nosocomial
49- The nurse receives a report on a newly admitted client who is positive for Clostridium difficile. Which
category of isolation would the nurse implement for this client?
Contact precautions
50- The nurse creates a plan of care for a client with a risk of infection. Which is the most desirable expected
outcome for the client?
The client will be free of signs and symptoms of infection by discharge.
51- A nurse manager in charge of a unit overhears two nurses in a hall filled with visitors discussing a client on
the unit who has AIDS. What should be the nurse manager's initial action?
Have a conference with the nurses and talk about the need for confidentiality.
52- It is appropriate for the nurse to pull up on the client's skin, release it, and determine if the skin returns
immediately to its original position to assess for:
Skin turgor
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