ALL HESI FUNDAMENTALS EXAM TEST BANK UPDATED 2024 COMPREHENSI VE QUESTIONS AND ANSWERS WITH RATIONALES Question 1: A nurse is caring for a client who is experiencing acute pain. Which of the following interventions should the nurse implement first? A. Administer prescribed pain medication. B. Assess the client's pain level. C. Reposition the client for comfort. D. Apply a warm compress to the area of pain. Answer: B. Assess the client's pain level. Rationale: The nurse should first assess the client's pain level to determine the severity and nature of the pain. This assessment will guide subsequent interventions to effectively manage the pain. Question 2: A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy at 2 liters per minute via nasal cannula. The nurse observes that the client's oxygen saturation is 88%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate to 3 liters per minute. B. Encourage the client to take deep breaths. C. Check the placement of the nasal cannula. D. Notify the healthcare provider. Answer: C. Check the placement of the nasal cannula. Rationale: The nurse should first ensure that the nasal cannula is properly placed and functioning correctly. Incorrect placement can result in decreased oxygen delivery and low oxygen saturation levels. Question 3: A nurse is teaching a client with hypertension about dietary modifications. Which of the following client statements indicates an understanding of the teaching? A. "I should reduce my intake of high -fat foods." B. "I should eat more fresh fruits and vegetables." C. "I should drink at least 3 liters of water per day." D. "I should limit my protein intake." Answer: B. "I should eat more fresh fruits and vegetables." Rationale: Increasing the intake of fresh fruits and vegetables is a key dietary modification for clients with hypertension as they are high in fiber, vitamins, and minerals, and low in sodium and fat. Question 4: A nurse is planning care for a client who is at risk for pressure ulcers. Which of the following interventions should the nurse include in the plan? A. Massage reddened areas to improve circulation. B. Use a donut -shaped cushion for sitting. C. Reposition the client every 2 hours. D. Apply cornstarch to keep skin dry. Answer: C. Reposition the client every 2 hours. Rationale: Regular repositioning helps to prevent pressure ulcers by relieving pressure on vulnerable areas of the body. Other interventions can potentially cause harm or are less effective in preventing pressure ulcers. Question 5: A client with diabetes mellitus asks the nurse about the importance of foot care. Which of the following instructions should the nurse include in the teaching? A. "Soak your feet in hot water every day." B. "Apply lotion between your toes to keep the skin soft." C. "Inspect your feet daily for any cuts or sores." D. "Trim your toenails straight across and round the edges." Answer: C. "Inspect your feet daily for any cuts or sores." Rationale: Clients with diabetes mellitus are at increased risk for foot injuries and infections due to neuropathy and poor circulation. Daily inspection of the feet helps to identify and address any problems early. Question 6: A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take to prevent the spread of infection? A. Wear a surgical mask at all times. B. Place the client in a private room. C. Perform hand hygiene before and after contact with the client. D. Administer prophylactic antibiotics to all close contacts. Answer: C. Perform hand hygiene before and after contact with the client. Rationale: Hand hygiene is the most effective measure to prevent the spread of infection. Wearing a mask and placing the client in a private room are additional precautions, but hand hygiene is essential. Question 7: A client is admitted with dehydration. Which of the following findings should the nurse expect to observe? A. Bradycardia B. Hypotension C. Jugular vein distension D. Peripheral edema Answer: B. Hypotension Rationale: Dehydration typically leads to decreased blood volume, which can result in hypotension. Other findings like bradycardia, jugular vein distension, and peripheral edema are less common in dehydration. Question 8: A nurse is providing discharge teaching to a client who is prescribed warfarin. Which of the following statements by the client indicates a need for further teaching? A. "I will avoid eating large amounts of leafy green vegetables." B. "I will use a soft toothbrush to brush my teeth." C. "I will take aspirin if I have a headache." D. "I will have my blood tested regularly." Answer: C. "I will take aspirin if I have a headache." Rationale: Aspirin can increase the risk of bleeding in clients taking warfarin. The client should be advised to avoid aspirin and other medications that can affect blood clotting. Question 9: A nurse is assessing a client who has heart failure. Which of the following findings is a priority to report to the provider? A. Weight gain of 1 kg (2.2 lb) in 24 hours B. Blood pressure of 140/90 mm Hg C. Mild dyspnea with exertion D. Peripheral edema in the ankles Answer: A. Weight gain of 1 kg (2.2 lb) in 24 hours Rationale: A rapid weight gain in a short period can indicate fluid retention, which is a sign of worsening heart failure and should be reported immediately. Question 10: A nurse is teaching a group of older adults about health promotion and disease prevention. Which of the following recommendations should the nurse include? A. "You should have a vision screening every 5 years."
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