HESI RN FUNDAMENTALS EXAM 2018
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administer a dose that is not within the prescribed parameters. What action should the nurse take first? C
The unlicensed assistive personnel (UAP) describes the appearance of the bowel movements of several clients. Which descriptions warrant additional follow-up by the nurse? (Select all that apply.) ABDE
An elderly woman comes to the clinic because of vaginal bleeding. The healthcare provider finds a vaginal tear, which the client reports is likely to have occurred during unprotected sexual intercourse. Which content is most important for the nurse to include in this client’s teaching plan? A
A male client has right-sided hemiplegia following a left cerebrovascular accident (CVA). His sitting balance has improved, and he is now able to sit In a wheelchair. To assist the client in transferring from the bed to a wheelchair, what action should the nurse take?
The nurse observes a newly admitted older adult female take short steps and walk very slowly while pushing a walker in front of her. What action should the nurse take in response to these observations? A
A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain. The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse administer?
(Round to the nearest tenth.) 1.5mg
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? C
An older woman with end stage heart disease is hospitalized for severe heart failure. She is alert, oriented, and requests that no heroic measures are implemented if her breathing stops. What action should the nurse take first? A
A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this client’s teaching? A
When assessing a client who starts to wheeze related data should obtain? D
The home health nurse is reviewing the personal care of an elderly client who lives alone.Which client assessment findings indicate the need to assign an unlicensed assistive personnel. (UAP) to provide routine foot care and file the client’s toenails? Select all that apply.) ABC
A client is discharged to a long-term care facility with an indwelling urinary catheter. Which nursing action should be included in the plan to reduce the client’s risk for infection related to the catheter? B
To assess the quality of an adult client’s pain, what approach should the nurse use? C
A client who has been diagnosed with terminal cancer tells the nurse, “The doctor told me I have cancer and do not have long to live.” Which response is best for the nurse to provide?
When performing blood pressure measurement to assess for orthostatic hypotension, which action should the nurse implement first? C
A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP request a change in assignment, stating she has not yet been fitted for a particulate filter mask. What action should the nurse take? D
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 policy requiring the removal of acrylic nails by all nursing personnel was implemented six months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?
A client with limited tolerance for activity needs to walk in the hallway with assistance. Which instructions should the nurse give to the unlicensed assisstive personnel (UAP) who assissting with client’s care? (Select all that apply.)
A client has begun a long-term maintenance therapy with lithium, which has a narrow therapeutic index. Which adverse effect is most important for nurse to include in the teaching plan?
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 client who lives in an assisted living facility develops cognitive impairment following a stroke. Informed consent is needed to provide additional nursing services. Who should nurse contact?
A client is in contact isolation due to stage IV coccyx wound infected with methicillin resistant staphylococcus aureus (MRSA). The nurse plans interventions to prevent multiple re-entries to the client’s room. In which order should the nurse perform the interventions?
What self-care outcome is best for the nurse to use in evaluating a client’s recovery form a stroke that resulted in left-sided hemiparesis?
A female client’s significant other has been at her bedside providing reassurance and support for past 3 days, as desired by the client. The client’s estranged husband arrives and demands the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
The nurse observes that there are reddened areas on the cheekbones of a client receiving oxygen per nasal cannula at 3L/minute, and the client’s oxygen saturation level is 92%. What intervention should the nurse implement?
A female nursing home resident and her family only speak Spanish. During a visit, the entire family begins to cry hysterically. When unable to determine why the family is upset, what intervention is most important for the nurse to implement?
The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant grandution. The wound has a gauze dressing covering the area. What action should the nurse implemented?
The healthcare provider prescribes haloperidol (Haldol) 1.5mg twice daily for a client with Tourette’s syndrome. The drug is available in a solution labeled, “2 mg/ml.” How many ml should the nurse administer? (Round to the nearest hundredth.)
A male client with limited mobility is discharged with home health services. When the home health nurse arrives, the client asks what he can do for the swelling in his legs. Which should nurse implement?
The home care nurse is teaching a client how to change the dressing on a new venous stasis ulcer. The client has a history of a deep vein thrombosis and is allergic to latex. When removing the adhesive bandages, the nurse observes skin redness surrounding the draining wound. What action should the nurse implemented?
The nurse measures the client’s blood pressure (BP) and notes that it is significantly higher than the previous reading. What should the nurse do next? (Select all that apply.)
A client is admitted with pneumonia and has a recent history of methicillin-resistant Staphylococcus aureus (MRSA). The client is placed in isolation. While caring for the client, which item should the nurse place in a designated biohazard bag before it is removed from the room?
A middle-aged male client tells the nurse that has weeks ago he began exercising four times a week to lose weight and to help him sleep better. He states that it still takes an hour to fall asleep at night. What action should the nurse implement?
Which landmarks are useful to the nurse when administering an intramuscular injection in ventrogluteal site?
A male Native American presents to the clinic with complaints of frequent abdominal cramping and nausea. He states that he has 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?
What information is most important for the nurse to obtain in determining a client’s need for referral for obesity counseling?
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 client. When the family leaves, what action should the nurse take first?
A client who has been taking diuretics for premenstrual swelling reports muscle weakness. Which serum electrolyte value should the nurse report to the healthcare provider?
The nurse is caring for a male client with diminished circulation in the lower extremities. The client washes his feet in the shower, but is unable to bend safely to dry his feet. While drying the client’s feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
A 24-hour urine specimen is being collected for analysis clearance. After explaining the procedures, the client tells the nurse that the first sample is in the urinal. When discarding this specimen, what action should the nurse take?