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2020 HESI Fundamentals Version 1
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2020 HESI Fundamentals Version 1
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2020 HESI Fundamentals Version 11. 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.
Acrylic nails are known to carry loads of bacteria and increase the risk of healthcare-associated
infections. Therefore, by banning the wearing of acrylic nails, you would expect the prevalence
of healthcare-associated infections to decrease. Acrylic nails have nothing to do with staff
induced injuries, needle-stick injuries, or patient satisfaction scores.
2. Which assessment data would provide the most accurate determination of proper placement
of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
This is a method used to determine proper placement of NG tubing, but not the most accurate.
B) Hearing air pass in the stomach after injecting air into the tubing.
This is a method used to determine proper placement of NG tubing, but not the most accurate.
C) Examining a chest x-ray obtained after the tubing was inserted.
After placing an NG-tube, the placement of the tube is confirmed via x-ray since it is the most
accurate way to ensure the tube has not been placed in the lungs, which would pose an aspiration
risk.
D) Checking the remaining length of tubing to ensure that the correct length was
inserted. This is not an indicator of proper placement. You could very well be in a lung.
3. The father of an 11-year-old client reports to the nurse that the client has been “wetting the
bed” since the passing of his mother and is concerned. Which action is most important for
the nurse to enact?
A. Reassure the father that it is normal for a pre-teen to wet the bed during puberty
B. Inform the father that nocturnal emissions are abnormal and his son is
developmentally delayed
C. Inform the father that it is most important to let the son know that nocturnal emissions
are normal after trauma
D. Refer the father and the client to a psychologist
It is common for adolescents to regress in their biological progression after experiencing a
severe trauma, like losing a parent, sibling, or friend. While uncomfortable for the adolescent
and parent, it is nothing to be concerned for. Often times, as the patient grieves or comes to
terms with the trauma, the nocturnal emissions will cease.
4. The nurse explains to an older adult male the procedure for collecting a 24-hour urine
specimen for creatinine clearance. Which action is most important for the nurse to include
in their care plan for the shift?
,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
An “older adult male” in the question may imply that the patient may have an altered mental
status or be demented. While suggesting, it is not directly stated, therefore (A) is inappropriate.
(B) is incorrect because the lab will be assessing the collection specimen after the test is
complete. (C) is correct because the nurse should first discard the first specimen, then begin to
collect and record the time the first urine specimen was collected. It is important to have strict
documentation for output, and to collect every urine specimen within that 24 hour period,
otherwise the test must be restarted. (D) defeats the purpose of the 24-hour urine collection test.
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 most beneficial?
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
While the client’s wife may be grieving and need support, the priority for the client and client’s
wife is to make sure the wife feels comfortable participating in the client’s care, if at all. Most
people have an easier time coming to terms with the death of a loved one when they are involved
in their care. (D) is a nice gesture, but will be more appropriate at a later time.
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 first?
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
BMI of 30 indicates the patient is obese. (A) While a good step, it is not what should be
completed first. (B) While a good step, it is not what should be completed first. (C) The best
thing to recommend is to have the patient keep a food journal to be able to go back and track
their calorie intake; it may be helpful when meal planning or creating a workout routine plan.
(D) Would be appropriate later.
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? (Select
all that apply).
A. Tops of the ear
B. Bridge of the nose
C. Around the nostrils
D. Over the cheeks
E. Across the forehead
, This is proper placement of a nasal cannula. Constant pressure from the tubing may create skin
damage to the areas of skin and bony prominences the nasal cannula will be resting on.
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
(B) is especially important in making sure the patient does not experience skin breakdown due
to excessive moisture. Keeping the client’s feet clean is necessary, but keeping the client’s feet
dry is extremely important in skin maintenance.
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
Looking up patients who are not under your direct care is a HIPPA violation and may result in
termination of employment, despite the patient’s status in society or your curiosity. The first
action to implement is to report to your Charge Nurse so he or she may report the incident to the
appropriate chain of command.
10. At 0100 on a male client’s second postoperative night, the client states he is unable 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
Although the patient has stated he is unable to sleep, the patient has also stated he has a plan, “to
read until feeling sleep”, which implies the patient plans to sleep. Therefore, (D) is not necessary
and (C ) is very unnecessary because it is a stronger sleep aid. Offering melatonin would be more
appropriate, but since it is not an option, (A) is correct. (B) does not help the client sleep in any
way.
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
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