2023 HESI RN Fundamentals Exam Question and Study Guide With Answers (75 Solved Questions)

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HESI RN FUNDAMENTALS EXAM QUESTIONS WITHANSWERS & RATIONALES LATEST UPDATE 2023 A+GUIDEHESIRNFUNDAMENTALS•A20-year-old femaleclient withanoticeable bodyodorhasrefusedtoshowerforthelast 3 days. She states, "I have been told that it is harmful to bathe during myperiod."Whichaction should thenursetakefirst?•Acceptanddocumenttheclient's wishtorefrainfrombathing.•Offertogivetheclientabedbath,avoidingtheperinealarea.•Obtainwrittenbrochuresaboutmenstruationtogivetotheclient.•Teachtheimportanceofpersonalhygieneduringmenstruationwiththeclient.:DRationale: Because a shower is most beneficial for the client in terms of hygiene, the clientshould receive teaching first, respecting any personal beliefs such as cultural or spiritualvalues.Afterclientteaching,theclient maystillchooseoptionAorB.Brochuresreinforcetheteaching.•A65-year-old clientwhoattendsanadultdaycareprogramandiswheelchair-mobilehas redness in the sacral area. Which instruction is most important for thenurse toprovide?•Takeavitaminsupplementtablet onceaday.•Changepositionsinthechairatleast every hour.•Increasedailyintakeofwater orotheroralfluids.•Purchaseanewermodelwheelchair.:BRationale: The most important teaching is to change positions frequently because pressure is themostsignificant factorrelated tothedevelopment ofpressureulcers.Increasedvitaminandfluid

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intake may also be beneficial and promote healing and reduce further risk. Option D is aninterventionoflastresortbecausethiswillbevery expensivefortheclient.•Afteraneedlestickoccurswhileremovingthecapfromasterileneedle,whichactionshould thenurseimplement?•Completeanincidentreport.•Selectanothersterile needle.•Disinfecttheneedlewithanalcoholswab.•Notifythesupervisorofthedepartmentimmediately.:BRationale: After a needle stick, the needle is considered used, so the nurse should discard itandselect another needle. Because the needle was sterile when the nurse was stuck and theneedlewasnotin contact withanyotherperson'sbodyfluids, thenursedoesnotneed tocompleteanincidentreportornotifytheoccupationalhealthnurse.Disinfectinganeedlewithanalcoholswabisnotinaccordancewithstandardsforsafepracticeandinfectioncontrol.•After receiving written and verbal instructions from a clinic nurse about anewlyprescribedmedication,aclientasksthenursewhattodoifquestionsariseaboutthemedicationaftergettinghome. Howshouldthe nurserespond?•ProvidetheclientwithalistofInternetsitesthatanswerfrequentlyaskedquestionsabout medications.•Advisetheclient toobtainacurrenteditionofadrugreferencebookfromalocalbookstoreorlibrary.•Reassuretheclientthatinformationaboutthemedication isincludedinthewritteninstructions.•Encouragetheclient tocalltheclinicnurseorhealthcareproviderifanyquestionsarise.:D

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Rationale: To ensure safe medication use, the nurse should encourage the client to call thenurseorhealthcareproviderifanyquestionsarise.Options A,B,andCmayallincludeusefulinformation, but these sources of information cannot evaluate the nature of theclient'squestionsand thefollow-up needed.•After the nurse tells an older client that an IV line needs to be inserted, the clientbecomesveryapprehensive,loudlyverbalizingadislikeforallhealthcareprovidersandnurses.How should thenurserespond?•Asktheclient toremainquietsotheprocedure canbeperformedsafely.•Concentrateoncompletingtheinsertionasefficiently as possible.•Calmlyreassuretheclientthatthediscomfortwillbetemporary.•Tell the client a joke as a means of distraction from the procedure.:CRationale:Thenurseshouldrespondwithacalmdemeanortohelpreducetheclient's apprehension.Afterrespondingcalmlytotheclient'sapprehension,thenursemayimplementtoensuresafecompletionof theprocedure.•Basedonthenursingdiagnosisofriskforinfection,whichintervention isbestforthenursetoimplement when providingcareforanolder incontinentclient?•Maintainstandardprecautions.•Initiatecontactisolation measures.•Insertanindwellingurinarycatheter.•Instructclientintheuseofadultdiapers.:ARationale: Thebestactiontodecreasetheriskofinfectioninvulnerableclientsishandwashing.Option B is not necessary unless the client has an infection. Option C increasesthe risk ofinfection. OptionDdoes notreducetherisk ofinfection.•Byrollingcontaminatedgloves inside-out,thenurseisaffectingwhichstepinthechainofinfection?

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•Modeoftransmission•Portalofentry•C.Reservoir•D.Portalofexit:ARationale:Thecontaminatedgloves serveasthemodeoftransmissionfromtheportalofexitofthe reservoir toaportalof entry.•Aclientbecomesangrywhilewaitingforasupervisedbreaktosmokeacigaretteoutsideand states, "I want to go outside now and smoke. It takes forever to get anythingdonehere!"Which interventionisbest forthenursetoimplement?•Encouragetheclient touse anicotine patch.•Reassuretheclient thatitisalmosttime foranother break.•Havetheclientleavetheunitwithanotherstaffmember.•Reviewthescheduleofoutdoorbreakswiththeclient.:DRationale: The best nursing action is to review the schedule of outdoor breaks and provideconcrete information about the schedule. Option A is contraindicated if the client wants tocontinuesmoking.OptionBisinsufficient toencourageatrustingrelationshipwiththeclient.Option Cispreferentialforthisclient only andisinconsistent with unitrules.•A client has a nasogastric tube connected to low intermittent suction. Whenadministeringmedicationsthroughthenasogastrictube,whichactionshouldthenursedofirst?•Clampthenasogastrictube.•Confirmplacementofthetube.•Useasyringetoinstill themedications.•Turnofftheintermittentsuctiondevice.:D

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Rationale:Thenurseshouldfirstturnoffthesuction andthen confirmplacementofthe tubeinthestomachbeforeinstillingthemedications.Topreventimmediateremovaloftheinstilledmedicationsandallowabsorption,thetubeshouldbeclampedforaperiodoftimebeforereconnecting thesuction.•AclienthasanursingdiagnosisofAlteredsleeppatternsrelatedtonocturia.Whichclient instructionis importantforthenursetoprovide?•Decreaseintakeoffluidsafter theeveningmeal.•Drinkaglassofcranberry juiceevery day.•Drinkaglassofwarmdecaffeinatedbeverageat bedtime.•Consultthehealthcareprovideraboutasleepingpill.:ARationale:Nocturiaisurinationduringthenight.OptionAishelpfultodecreasetheproductionofurine,thusdecreasingtheneedtovoidatnight.OptionBhelpspreventbladderinfections.OptionCmaypromotesleep,butthefluidwillcontributetonocturia.OptionDmayresultinurinary incontinenceif the clientis sedated anddoes notawakentovoid.•A client in a long-term care facility reports to the nurse that he has nothad abowelmovementin2days.Whichinterventionshouldthenurseimplementfirst?•Instructthecaregivertoofferaglassofwarmprunejuice atmealtimes.•Notifythehealthcareproviderandrequestaprescriptionforalarge-volumeenema.•Assesstheclient'smedicalrecordtodeterminetheclient'snormalbowelpattern.•Instructthecaregiver toincreasetheclient's fluidstofive8-ounceglassesperday.:C

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Rationale:This clientmaynotroutinelyhaveadailybowelmovement,sothenurseshouldfirstassess this client's normal bowel habits before attempting any intervention. Option A, B,or Dmay then beimplemented,if warranted.•Aclient's bloodpressurereadingis156/94mmHg.Which actionshouldthenursetakefirst?•Telltheclient thatthebloodpressureishighandthatthereadingneedstobeverifiedby anothernurse.•Contactthehealth careprovidertoreportthereadingandobtainaprescriptionforanantihypertensivemedication.•Replacethecuffwithalarger onetoensureanamplefitforthe clienttoincreasearmcomfort.•Comparethecurrentreadingwiththeclient'spreviouslydocumentedbloodpressure readings.:DRationale: Comparingthisreadingwithpreviousreadingswillprovideinformation aboutwhatisnormal for this client; this action should be taken first. Option A might unnecessarilyalarm theclient. Option B is premature. Further assessment is needed to determine if thereading isabnormal for this client. Option C could falsely decrease the reading and is not thecorrectprocedure for obtainingablood pressurereading.•Acommunityhospitalisopeningamentalhealthservices department.Whichdocumentshouldthenurseusetodeveloptheunit's nursingguidelines?•AmericanswithDisabilities Actof 1990B.ANA Codeof Ethics with InterpretativeStatementsC.ANA's Scope and Standards of

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Nursing PracticeD.Patient'sBillof Rights of1990:CRationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursingservestodirectthephilosophyandstandardsofpsychiatricnursingpractice. OptionsAandDdefine the client's rights. OptionBprovidesethicalguidelinesfor nursing.•During a clinic visit, the mother of a 7-year-old reports to the nurse that her childisoftenawakeuntilmidnight playingandisthenverydifficult toawakeninthemorningforschool.Whichassessmentdatashouldthe nurse obtaininresponsetothemother'sreport?•Theoccurrenceofanyepisodesofsleepapnea•Thechild'sbloodpressure,pulse,andrespirations•Lengthofrapideyemovement(REM)sleep thatthechild isexperiencingD.Descriptionof thefamily'shomeenvironment:DRationale: School-age children often resist bedtime. The nurse should begin by assessing theenvironmentofthehometodeterminefactorsthatmaynotbeconducivetotheestablishmentofbedtimeritualsthatpromotesleep.OptionAoftencausesdaytime fatigueratherthanresistancetogoingtosleep.OptionBisunlikelytoprovideusefuldata.ThenursecannotdetermineoptionC.•During a routine assessment, an obese 50-year-old female client expresses concernabouthersexualrelationshipwithherhusband.Whichisthebestresponsebythenurse?•Reassuretheclientthatmanyobesepeoplehaveconcernsaboutsex.•Remindtheclientthatsexualrelationshipsneednotbeaffected byobesity.

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•Determine the frequency of sexualintercourse.D.Asktheclienttotalkaboutspecific concerns.:DRationale: Option D provides an opportunity for the client to verbalize her concerns andprovides the nurse with more assessment data. Options A and B may not be related to hercurrentconcern,assumethatobesityistheproblem,andarecommunicationblocks.OptionCmaybeappropriate afterdiscussingtheconcernsshe is having.•During evacuation of a group of clients from a medical unit because of a fire,thenurseobservesanambulatoryclientwalkingalonetowardthestairwayattheendofthehall. Which actionshould thenursetake?•Assignanunlicensedassistivepersonneltotransporttheclientviaawheelchair.•Remindtheclienttowalkcarefullydownthestairsuntilreachingalowerfloor.•Asktheclienttohelpbyassistingawheelchair-boundclienttoanearbyelevator.•Opentheclosestfire doorssothatambulatory clients canevacuatemore rapidly.:BRationale: Duringevacuation ofaunitbecauseoffire,ambulatoryclientsshouldbeevacuatedvia the stairway if at all possible and reminded to walk carefully. Ambulatoryclients do notrequire the assistance of a wheelchair to be evacuated. Elevators should notbe used during afire,andfiredoorsshould bekeptclosed tohelpcontainthefire.•A female client with frequent urinary tract infections (UTIs) asks the nurse toexplainher friend's advice about drinking a glass of juice daily to prevent futureUTIs. Whichresponseis best forthenursetoprovide?•Orangejuicehasvitamin Cthatdetersbacterialgrowth.•Applejuiceisthemostuseful inacidifyingtheurine.

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•Cranberry juice stops pathogens' adherence to thebladder.D.Grapefruitjuiceincreases absorptionofmostantibiotics.:CRationale:Cranberryjuicemaintains urinary tract health byreducing theadherenceofEscherichiacolibacteriatocells withinthebladder.OptionsA,B,andDhavenotbeenshowntobeas effectiveas cranberryjuiceinpreventingUTIs.•The health care provider has changed a client's prescription from the PO to the IVrouteofadministration.Thenurseshouldanticipatewhichchangeinthepharmacokineticpropertiesof themedication?•Theclientwillexperience increasedtolerancetothedrug'seffectsandmayneedahigher dose.•Theonsetofaction ofthedrugwilloccurmorerapidly,resultinginamorerapideffect.•Themedicationwillbemorehighlyprotein-bound,increasingthedurationofaction.•Thetherapeuticindexwillbeincreased,placingtheclientatgreaterriskfortoxicity.:BRationale: Because the absorptive process is eliminated when medications are administeredviathe IV route, the onset of action is more rapid, resulting in a more immediate effect. Drugtolerance, protein binding, and the drug's therapeutic index are not affected by the change inroutefromPOtoIV.Inaddition,anincreasedtherapeuticindexreduces theriskofdrugtoxicity.•Ahospitalized clienthashaddifficultyfallingasleep fortwonightsandisbecomingirritableandrestless.Whichactionbythenurseisbest?

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•Determinetheclient'susualbedtimeroutineandincludetheserituals intheplanofcareas safety allows.•InstructtheUAPnottowaketheclientunder anycircumstancesduringthenight.•Placea"DoNotDisturb"signonthedoorandchangeassessmentsfromevery4toevery8 hours.•Encouragetheclienttoavoidpainmedication duringtheday,whichmightincrease daytimenapping.:ARationale: Includinghabitualrituals thatdonotinterfere withtheclient's careorsafety mayallow the client to go to sleep faster and increase the quality of care. Options B, C, and Ddecrease theclient'sstandardof careandcompromise safety.•Inassistinganolderadultclientpreparetotake atubbath,whichnursingactionismostimportant?•Checkthebathwatertemperature.•Shutthebathroom door.•Ensurethattheclienthasvoided.•Provideextratowels.:ARationale: To prevent burns or excessive chilling, the nurse must check the bath watertemperature. OptionsB,C,andDpromotecomfortandprivacyandareimportantinterventionsbutareof less prioritythan promoting safety.•Incompletingaclient'spreoperativeroutine,thenursefindsthattheoperativepermitisnotsigned.The clientbeginstoaskmorequestionsaboutthesurgicalprocedure.Whichaction should thenursetakenext?A.Witnesstheclient's signaturetothepermit.•Answertheclient's questionsaboutthesurgery.

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•Informthesurgeonthattheoperative permitisnotsignedandtheclienthasquestionsabout thesurgery.•Reassuretheclientthatthesurgeon willansweranyquestionsbeforetheanesthesiaisadministered.:CRationale: The surgeon should be informed immediately that the permit is not signed. It isthesurgeon'sresponsibilitytoexplaintheproceduretotheclientandobtaintheclient'ssignatureonthe permit. Although the nurse can witness an operative permit, the proceduremust first beexplainedbythe healthcareproviderorsurgeon,includingansweringtheclient's questions.Theclient'squestionsshouldbeaddressedbeforethepermitissigned.•In taking a client's history, the nurse asks about the stool characteristics.Whichdescriptionshouldthenursereporttothe healthcareproviderassoonaspossible?•Dailyblack,stickystool•DailydarkbrownstoolC.Firm brownstooleveryotherdayD.Softlightbrownstooltwiceaday:ARationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should bereportedtothehealthcareproviderpromptly.OptionCindicates constipation,whichisalesserpriority. OptionsBand Darevariationsof normal.•A male client is laughing at a television program with his wife when theeveningnurseenterstheroom.He sayshisfootishurtingandhewouldlikeapainpill. Howshouldthenurserespond?•Askhimto ratehis painona scaleof 1to10.•Encouragehimtowaituntilbedtime sothepill canhelphimsleep.•Attendtoanacutelyillclient'sneedsfirstbecausethisclientislaughing.

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