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HESI FUNDAMENTALS 2021
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HESI FUNDAMENTALS 2021
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HESI Fundamentals Exam
2021
, HESI FUNDAMENTALS 2021
Replace a. with a and u. with u
1. A. policy requ.iring the remova.l of a.crylic na.ils by a.ll nu.rsing personnel wa.s
implemented 6 months a.go. Which a.ssessment mea.su.re best determines if the intended
ou.tcome of the policy is being a.chieved.
a. Nu.mber of sta.ff indu.ced inju.ry
b. Client sa.tisfa.ction su.rvey
c. Hea.lth ca.re-a.ssocia.ted infection ra.te.
d. Ra.te of needle-stick inju.ries by nu.rse.
2. The nu.rse is prepa.ring to a.ssist a. newly a.dmitted client with persona.l hygiene mea.su.res.
The client...the client’s ga.g reflex. Which a.ction shou.ld the nu.rse inclu.de?
A. Offer sma.lls sips of wa.ter throu.gh a. stra.w
B. Pla.ce tongu.e bla.de on ba.ck ha.lf of tongu.e
C. U.se a. penlight to observe ba.ck of ora.l ca.vity
D. A.u.scu.lta.te brea.th sou.nds a.fter client swa.llows
3. The nu.rse expla.ins to a.n older a.du.lt ma.le the procedu.re for collecting a. 24-hou.r u.rine
specimen for crea.tinine clea.ra.nce.
A. A.ssess the client for confu.sion a.nd retea.ch the procedu.re
B. Check the u.rine for color a.nd textu.re
C. Empty the u.rina.l contents into the 24-hou.r collection conta.iner
D. Disca.rd the contents of the u.rina.l
4. A. 54-yea.r-old ma.le client a.nd his wife were informed this morning tha.t he ha.s termina.l
ca.ncer. Which nu.rsing intervention is likely to be
most
A. A.sk her how she wou.ld like to pa.rticipa.te in the client’s ca.re
B. Provide the wife with informa.tion a.bou.t hospice
C. Encou.ra.ge the wife to visit a.fter pa.infu.l trea.tments a.re completed
D. Refer her to su.pport grou.p for fa.mily members of those dying of
ca.ncer
5. A. client who ha.s a. body ma.ss index (BMI) of 30 is requ.esting informa.tion on the initia.l
a.pproa.ch to a. weight loss pla.n. Which a.ction shou.ld the nu.rse recommend?
A. Pla.n low ca.rbohydra.te a.nd high protein mea.ls
B. Enga.ge in strenu.ou.s a.ctivity for a.n hou.r da.ily
C. Keep a. record of food a.nd drinks consu.med da.ily
D. Pa.rticipa.ted in a. grou.p exercise cla.ss 3 times a. week
6. The nu.rse a.ssesses a. client who ha.s a. na.sa.l ca.nnu.la. delivering oxygen a.t 2 L/min. To
a.ssess for skin da.ma.ge rela.ted to the ca.nnu.la., which a.rea.s shou.ld the nu.rse observe?
A. Tops of the ea.r
B. Bridge of the nose
C. A.rou.nd the
D. nostrils
E. Over the A.cross the forehea.d
7. The nu.rse observes cheeks a.n u.nlicensed a.ssistive personnel (U.A.P) who is
providing a. tota.l bed ba.th for a. confu.sed a.nd letha.rgic client. The U.A.P
is soa.king the client’s foot in a. ba.sin of wa.rm wa.ter pla.ced on the bed. Wha.t a.ction
shou.ld the nu.rse ta.ke?
a. Remove the ba.sin of wa.ter from the client’s bed immedia.tely
, b. Remind the U.A.P to dry between the client’s toes completely
c. A.dvise the U.A.P tha.t this procedu.re is da.ma.ging to the skin
d. A.dd skin crea.m to the ba.sin of wa.ter while the foot is soa.king
8. The nu.rse in the emergency depa.rtment observes a. collea.gu.e viewing the electronic
hea.lth record (EHR) of a. client who holds a.n elected position in the commu.nity. The client
is not a. pa.rt of the collea.gu.e’s a.ssignment. Which a.ction shou.ld the nu.rse implement?
a. Commu.nica.te the collea.gu.e’s a.ctions to the u.nit cha.rge nu.rse
b. Send a.n ema.il to fa.cility a.dministra.tion reporting the a.ction
c. Write a.n a.nonymou.s compla.int to a. professiona.l website
d. Post a. comment a.bou.t the a.ction on a. sta.ff discu.ssion boa.rd
9. A.t 0100 on a. ma.le client’s second postopera.tive night, the client sta.tes he is u.nsta.ble to
sleep a.nd pla.ns to rea.d u.ntil feeling sleepy. Wha.t a.ction shou.ld the nu.rse implement?
a. Lea.ve the room a.nd close the door to the client’s room
b. A.ssess the a.ppea.ra.nce of the client’s su.rgica.l dressing
c. Bring the client a. prescribed PRN seda.tive-hypnotic
d. Discu.ss symptoms of sleep depriva.tion with the client
10. The nu.rsing sta.ff in the ca.rdiova.scu.la.r intensive ca.re u.nit a.re crea.ting a.
continu.ou.s qu.a.lity improvement project on socia.l media. tha.t a.ddresses corona.ry a.rtery
disea.se (CA.D). Which a.ction shou.ld the nu.rse implement to protect client priva.cy?
a. Remove identifying informa.tion of the clients who pa.rticipa.ted
b. Reca.ll tha.t a.u.thored content ma.y be lega.lly discovera.ble
c. Sha.re ma.teria.l from credible, peer reviewed sou.rces only
d. Respect a.ll copyright la.ws when a.dding website content
11. A. ma.le client with u.nsta.ble a.ngina. needs a. ca.rdia.c ca.theteriza.tion, so the
hea.lthca.re provider expla.ins the risks a.nd benefits of the procedu.re, a.nd then lea.ves to
set u.p for the procedu.re. When the nu.rse presents the consent form for signa.tu.re, the client
hesita.tes a.nd a.sks how the wires will keep his hea.rt going. Which a.ction shou.ld the nu.rse
ta.ke?
a. A.nswer the client’s specific qu.estions with a. short u.ndersta.nda.ble
expla.na.tion
b. Postpone the procedu.re u.ntil the client u.ndersta.nds the risks a.nd
benefits
c. Ca.ll the client’s next of kin a.nd a.sk them to provide verba.l consent
d. Pa.ge the hea.lthca.re provider to retu.rn a.nd provide a.dditiona.l
expla.na.tion
12. The nu.rse is tea.ching a. client how to do a.ctive ra.nge of motion (ROM) exercises. To
exercise the hinge joints, which a.ction shou.ld the nu.rse instru.ct the client to perform?
a. Tilt the pelvis forwa.rds a.nd ba.ckwa.rds
b. bend the a.rm by flexing the u.lna.r to the hu.meru.s
c. Tu.rn the hea.d to the right a.nd left
d. Extend the a.rm a.t the ide a.nd rota.te in circles
, 13. A. postopera.tive client ha.s three different PRN a.na.lgesics prescribed for different levels
of pa.in. The nu.rse ina.dvertently a.dministers a. dose tha.t is not within the prescribed
pa.ra.meters. Wha.t a.ctions shou.ld the nu.rse ta.ke first?
a. A.ccess for side effects of the medica.tion.
b. Docu.ment the client’s responses.
c. complete a. medica.tion error report.
d. Determine if the pa.in wa.s relieved.
14. When a.ssessing a. ma.le client, the nu.rse finds tha.t he is fa.tigu.e, a.nd is experiencing
mu.scle wea.kness, leg cra.mps, a.nd ca.rdia.c dysrhythmia.s. Ba.sed on these findings, the
nu.rse pla.ns to check the client’s la.bora.tory va.lu.es to va.lida.te the existence of which?
a. Hyperphospha.temia.
b. Hypoca.lcemia.
c. Hyperma.gnesemia.
d. Hypoka.lemia.
15. A. fema.le client’s significa.nt other ha.s been a.t her bedside providing rea.ssu.ra.nces a.nd
su.pport for the pa.st 3da.ys, a.s desired by the client. The client’s estra.nged hu.sba.nd
a.rrives a.nd dema.nds tha.t the significa.nt other not be a.llowed to visit or be given
condition u.pda.tes. Which intervention shou.ld the nu.rse implement?
a. Obta.in a. perception from the hea.lthca.re provider rega.rding
visita.tion privileges
b. Requ.est a. consu.lta.tion with the ethics committee for resolu.tion of
the situ.a.tion
c. Encou.ra.ge the client to spea.k with her hu.sba.nd rega.rding his
disru.ptive beha.vior
d. Commu.nica.te the client’s wishes to a.ll members of the
mu.ltidisciplina.ry tea.m
16. When mea.su.ring vita.l signs, the nu.rse observes tha.t a. client is u.sing a.ccessory neck
mu.scles du.ring respira.tions. Wha.t follow-u.p a.ction shou.ld the nu.rse ta.ke first?
a. Determine pu.lse pressu.re
b. A.u.scu.lta.te hea.rt sou.nds
c. Mea.su.re oxygen sa.tu.ra.tion
d. Check for neck vein distention
17. To a.void nerve inju.ry, wha.t loca.tion shou.ld the nu.rse select to a.dminister a. 3 mL IM
injection?
a. Ventroglu.tea.l
b. ou.ter u.pper qu.a.dra.nt of the bu.ttock
c. Two inches below the a.cromion process
d. Va.stu.s la.tera.lis
18. Which instru.ction shou.ld the nu.rse inclu.de in the discha.rge tea.ching pla.n for a.n
a.du.lt client with hyperna.tremia.?
a. Monitor da.ily u.rine ou.tpu.t volu.me
b. Drink plenty of wa.ter whenever thirsty
c. U.se sa.lt ta.blets for sodiu.m content
d. Review food la.bels for sodiu.m content
19. While cha.nging a. client’s post opera.tive dressing, the nu.rse observes a. red a.nd swollen
wou.nd with a. modera.te a.mou.nt of yellow a.nd green dra.ina.ge a.nd a. fou.l odor.
Given there is a. positive MRSA., which is the most importa.nt a.ction for the nu.rse to
ta.ke?
A. Force ora.l flu.ids
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