HESI Stephen F. Austin State University RN Fundamentals Practice Exam With Answers (75 Solved Questions)

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1HESI RN FUNDAMENTALS1. A 20-year-old female client with a noticeable body odor has refused to shower for thelast 3 days. She states, "I have been told that it is harmful to bathe during my period."Which action should the nurse take first?A.Accept and document the client's wish to refrain from bathing.B.Offer to give the client a bed bath, avoiding the perineal area.C.Obtain written brochures about menstruation to give to the client.D.Teach the importance of personal hygiene during menstruation with the client.: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 spiritual values.After client teaching, the client may still choose option A or B. Brochures reinforce the teaching.2. A 65-year-old client who attends an adult daycare program and is wheelchair-mobilehas redness in the sacral area. Which instruction is most important for the nurse toprovide?A.Take a vitamin supplement tablet once a day.B.Change positions in the chair at least every hour.C.Increase daily intake of water or other oral fluids.D.Purchase a newer model wheelchair.:BRationale: The most important teaching is to change positions frequently because pressure is themost significant factor related to the development of pressure ulcers. Increased vitamin and fluidintake may also be beneficial and promote healing and reduce further risk. Option D is anintervention of last resort because this will be very expensive for the client.3. After a needle stick occurs while removing the cap from a sterile needle, whichaction should the nurse implement?lOMoARcPSD|13778330

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A.Complete an incident report.B.Select another sterile needle.C.Disinfect the needle with an alcohol swab.D.Notify the supervisor of the department immediately.:BRationale: After a needle stick, the needle is considered used, so the nurse should discard it andselect another needle. Because the needle was sterile when the nurse was stuck and the needlewas not in contact with any other person's body fluids, the nurse does not need to complete an

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incident report or notify the occupational health nurse. Disinfecting a needle with an alcoholswab is not in accordance with standards for safe practice and infection control.4. After receiving written and verbal instructions from a clinic nurse about a newlyprescribed medication, a client asks the nurse what to do if questions arise about themedication after getting home. How should the nurse respond?A.Provide the client with a list of Internet sites that answer frequently askedquestions about medications.B.Advise the client to obtain a current edition of a drug reference book from alocal bookstore or library.C.Reassure the client that information about the medication is included in thewritten instructions.D.Encourage the client to call the clinic nurse or health care provider if anyquestions arise.:DRationale: To ensure safe medication use, the nurse should encourage the client to call thenurse or health care provider if any questions arise. Options A, B, and C may all include usefulinformation, but these sources of information cannot evaluate the nature of the client'squestions and the follow-up needed.5. After the nurse tells an older client that an IV line needs to be inserted, the clientbecomes very apprehensive, loudly verbalizing a dislike for all health care providers andnurses. How should the nurse respond?A.Ask the client to remain quiet so the procedure can be performed safely.B.Concentrate on completing the insertion as efficiently as possible.C.Calmly reassure the client that the discomfort will be temporary.D.Tell the client a joke as a means of distraction from the procedure.:CRationale: The nurse should respond with a calm demeanor to help reduce the client'sapprehension. After responding calmly to the client's apprehension, the nurse may implement toensure safe completion of the procedure.lOMoARcPSD|13778330

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6. Based on the nursing diagnosis of risk for infection, which intervention is best for thenurse to implement when providing care for an older incontinent client?A.Maintain standard precautions.B.Initiate contact isolation measures.C.Insert an indwelling urinary catheter.

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D.Instruct client in the use of adult diapers.:ARationale: The best action to decrease the risk of infection in vulnerable clients is handwashing.Option B is not necessary unless the client has an infection. Option C increases the risk ofinfection. Option D does not reduce the risk of infection.7. By rolling contaminated gloves inside-out, the nurse is affecting which step in the chainof infection?A.Mode of transmissionB.Portal of entryC.ReservoirD.Portal of exit:ARationale: The contaminated gloves serve as the mode of transmission from the portal of exit ofthe reservoir to a portal of entry.8. A client becomes angry while waiting for a supervised break to smoke a cigarette outsideand states, "I want to go outside now and smoke. It takes forever to get anything donehere!" Which intervention is best for the nurse to implement?A.Encourage the client to use a nicotine patch.B.Reassure the client that it is almost time for another break.C.Have the client leave the unit with another staff member.D.Review the schedule of outdoor breaks with the client.: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 tocontinue smoking. Option B is insufficient to encourage a trusting relationship with the client.Option C is preferential for this client only and is inconsistent with unit rules.9. A client has a nasogastric tube connected to low intermittent suction. Whenadministering medications through the nasogastric tube, which action should the nurse dofirst?

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A.Clamp the nasogastric tube.B.Confirm placement of the tube.C.Use a syringe to instill the medications.D.Turn off the intermittent suction device.:DRationale: The nurse should first turn off the suction and then confirm placement of the tube inthe stomach before instilling the medications. To prevent immediate removal of the instilledlOMoARcPSD|13778330

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medications and allow absorption, the tube should be clamped for a period of time beforereconnecting the suction.10. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Whichclient instruction is important for the nurse to provide?A.Decrease intake of fluids after the evening meal.B.Drink a glass of cranberry juice every day.C.Drink a glass of warm decaffeinated beverage at bedtime.D.Consult the health care provider about a sleeping pill.:ARationale: Nocturia is urination during the night. Option A is helpful to decrease the productionof urine, thus decreasing the need to void at night. Option B helps prevent bladder infections.Option C may promote sleep, but the fluid will contribute to nocturia. Option D may result inurinary incontinence if the client is sedated and does not awaken to void.11. A client in a long-term care facility reports to the nurse that he has not had abowel movement in 2 days. Which intervention should the nurse implement first?A.Instruct the caregiver to offer a glass of warm prune juice at mealtimes.B.Notify the health care provider and request a prescription for a large-volume enema.C.Assess the client's medical record to determine the client's normal bowel pattern.D.Instruct the caregiver to increase the client's fluids to five 8-ounce glasses per day.:CRationale: This client may not routinely have a daily bowel movement, so the nurse should firstassess this client's normal bowel habits before attempting any intervention. Option A, B, or Dmay then be implemented, if warranted.12. A client's blood pressure reading is 156/94 mm Hg. Which action should the nursetake first?A.Tell the client that the blood pressure is high and that the reading needs to beverified by another nurse.lOMoARcPSD|13778330

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B.Contact the health care provider to report the reading and obtain a prescription foran antihypertensive medication.C.Replace the cuff with a larger one to ensure an ample fit for the client to increasearm comfort.D.Compare the current reading with the client's previously documented bloodpressure readings.:D

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Rationale: Comparing this reading with previous readings will provide information about what isnormal for this client; this action should be taken first. Option A might unnecessarily alarm theclient. Option B is premature. Further assessment is needed to determine if the reading isabnormal for this client. Option C could falsely decrease the reading and is not the correctprocedure for obtaining a blood pressure reading.13. A community hospital is opening a mental health services department. Whichdocument should the nurse use to develop the unit's nursing guidelines?A.Americans with Disabilities Act of 1990B.ANA Code of Ethics with Interpretative StatementsC.ANA's Scope and Standards of Nursing PracticeD.Patient's Bill of Rights of 1990:CRationale: The ANA Scope of Standards of Practice for Psychiatric-Mental Health Nursingserves to direct the philosophy and standards of psychiatric nursing practice. Options A and Ddefine the client's rights. Option B provides ethical guidelines for nursing.14. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child isoften awake until midnight playing and is then very difficult to awaken in the morning forschool. Which assessment data should the nurse obtain in response to the mother'sreport?A.The occurrence of any episodes of sleep apneaB.The child's blood pressure, pulse, and respirationsC.Length of rapid eye movement (REM) sleep that the child is experiencingD.Description of the family's home environment:DRationale: School-age children often resist bedtime. The nurse should begin by assessing theenvironment of the home to determine factors that may not be conducive to the establishment ofbedtime rituals that promote sleep. Option A often causes daytime fatigue rather than resistancelOMoARcPSD|13778330

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to going to sleep. Option B is unlikely to provide useful data. The nurse cannot determine optionC.15. During a routine assessment, an obese 50-year-old female client expresses concernabout her sexual relationship with her husband. Which is the best response by the nurse?A.Reassure the client that many obese people have concerns about sex.B.Remind the client that sexual relationships need not be affected by obesity.C.Determine the frequency of sexual intercourse.D.Ask the client to talk about specific concerns.:DlOMoARcPSD|13778330

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Rationale: 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 hercurrent concern, assume that obesity is the problem, and are communication blocks. Option Cmay be appropriate after discussing the concerns she is having.16. During evacuation of a group of clients from a medical unit because of a fire, thenurse observes an ambulatory client walking alone toward the stairway at the end ofthe hall. Which action should the nurse take?A.Assign an unlicensed assistive personnel to transport the client via a wheelchair.B.Remind the client to walk carefully down the stairs until reaching a lower floor.C.Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.D.Open the closest fire doors so that ambulatory clients can evacuate more rapidly.:BRationale: During evacuation of a unit because of fire, ambulatory clients should be evacuatedvia the stairway if at all possible and reminded to walk carefully. Ambulatory clients do notrequire the assistance of a wheelchair to be evacuated. Elevators should not be used during afire, and fire doors should be kept closed to help contain the fire.17. A female client with frequent urinary tract infections (UTIs) asks the nurse to explainher friend's advice about drinking a glass of juice daily to prevent future UTIs. Whichresponse is best for the nurse to provide?A.Orange juice has vitamin C that deters bacterial growth.B.Apple juice is the most useful in acidifying the urine.C.Cranberry juice stops pathogens' adherence to the bladder.D.Grapefruit juice increases absorption of most antibiotics.:CRationale: Cranberry juice maintains urinary tract health by reducing the adherence ofEscherichia coli bacteria to cells within the bladder. Options A, B, and D have not been shown tobe as effective as cranberry juice in preventing UTIs.lOMoARcPSD|13778330

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18. The health care provider has changed a client's prescription from the PO to the IVroute of administration. The nurse should anticipate which change in the pharmacokineticproperties of the medication?A.The client will experience increased tolerance to the drug's effects and may needa higher dose.B.The onset of action of the drug will occur more rapidly, resulting in a more rapideffect.C.The medication will be more highly protein-bound, increasing the duration of action.lOMoARcPSD|13778330

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D.The therapeutic index will be increased, placing the client at greater risk for toxicity.:BRationale: Because the absorptive process is eliminated when medications are administered viathe 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 inroute from PO to IV. In addition, an increased therapeutic index reduces the risk of drug toxicity.19. A hospitalized client has had difficulty falling asleep for two nights and isbecoming irritable and restless. Which action by the nurse is best?A.Determine the client's usual bedtime routine and include these rituals in the planof care as safety allows.B.Instruct the UAP not to wake the client under any circumstances during the night.C.Place a "Do Not Disturb" sign on the door and change assessments from every 4to every 8 hours.D.Encourage the client to avoid pain medication during the day, which mightincrease daytime napping.:ARationale: Including habitual rituals that do not interfere with the client's care or safety mayallow the client to go to sleep faster and increase the quality of care. Options B, C, and Ddecrease the client's standard of care and compromise safety.20. In assisting an older adult client prepare to take a tub bath, which nursing action ismost important?A.Check the bath water temperature.B.Shut the bathroom door.C.Ensure that the client has voided.D.Provide extra towels.:AlOMoARcPSD|13778330

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Rationale: To prevent burns or excessive chilling, the nurse must check the bath watertemperature. Options B, C, and D promote comfort and privacy and are important interventionsbut are of less priority than promoting safety.21. In completing a client's preoperative routine, the nurse finds that the operative permitis not signed. The client begins to ask more questions about the surgical procedure.Which action should the nurse take next?A.Witness the client's signature to the permit.B.Answer the client's questions about the surgery.lOMoARcPSD|13778330

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C.Inform the surgeon that the operative permit is not signed and the client hasquestions about the surgery.D.Reassure the client that the surgeon will answer any questions before the anesthesiais administered.:CRationale: The surgeon should be informed immediately that the permit is not signed. It is thesurgeon's responsibility to explain the procedure to the client and obtain the client's signature onthe permit. Although the nurse can witness an operative permit, the procedure must first beexplained by the health care provider or surgeon, including answering the client's questions.The client's questions should be addressed before the permit is signed.22. In taking a client's history, the nurse asks about the stool characteristics.Which description should the nurse report to the health care provider as soon aspossible?A.Daily black, sticky stoolB.Daily dark brown stoolC.Firm brown stool every other dayD.Soft light brown stool twice a day:ARationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should bereported to the health care provider promptly. Option C indicates constipation, which is a lesserpriority. Options B and D are variations of normal.23. A male client is laughing at a television program with his wife when the eveningnurse enters the room. He says his foot is hurting and he would like a pain pill. Howshould the nurse respond?A.Ask him to rate his pain on a scale of 1 to 10.B.Encourage him to wait until bedtime so the pill can help him sleep.C.Attend to an acutely ill client's needs first because this client is laughing.D.Instruct him in the use of deep breathing exercises for pain control.:AlOMoARcPSD|13778330

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