HESI RN Fundamentals, Exams of Nursing

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HESI RN Fundamentals A 20-year-old female client with a noticeable body odor has refused to shower for the last 3 days. She states, "| 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. - Correct Answer Teach the importance of personal hygiene during menstruation with the client. A 65-year-old client who attends an adult daycare program and is wheelchair- mobile has redness in the sacral area. Which instruction is most important for the nurse to provide? 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 - Correct Answer Change positions in the chair at least every hour. After a needle stick occurs while removing the cap from a sterile needle, which action should the nurse implement? 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. - Correct Answer Select another sterile needle. After receiving written and verbal instructions from a clinic nurse about a newly prescribed medication, a client asks the nurse what to do if questions arise about the medication after getting home. How should the nurse respond? A. Provide the client with a list of Internet sites that answer frequently asked questions about medications. B. Advise the client to obtain a current edition of a drug reference book from a local bookstore or library. C.Reassure the client that information about the medication is included in the written instructions. D. Encourage the client to call the clinic nurse or health care provider if any questions arise. - Correct Answer Encourage the client to call the clinic nurse or health care provider if any questions arise. D.Portal of exit - Correct Answer Mode of transmission A client becomes angry while waiting for a supervised break to smoke a cigarette outsideand states, "| want to go outside now and smoke. It takes forever to get anything done here!" 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. - Correct Answer Review the schedule of outdoor breaks with the client. A client has a nasogastric tube connected to low intermittent suction. When administering medications through the nasogastric tube, which action should the nurse dofirst? 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. - Correct Answer Turn off the intermittent suction device. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client 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. - Correct Answer Decrease intake of fluids after the evening meal. A client in a long-term care facility reports to the nurse that he has not had a bowel 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. - Correct Answer Assess the client's medical record to determine the client's normal bowel pattern. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first? A.Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. C.Length of rapid eye movement (REM) sleep that the child is experiencing D.Description of the family's home environment - Correct Answer Description of the family's home environment During a routine assessment, an obese 50-year-old female client expresses concern about 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. - Correct Answer Ask the client to talk about specific concerns. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the 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. - Correct Answer Remind the client to walk carefully down the stairs until reaching a lower floor. 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. - Correct Answer Cranberry juice stops pathogens’ adherence to the bladder. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties 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 rapid effect. C. The medication will be more highly protein-bound, increasing the duration of action. 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. C.Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. D.Reassure the client that the surgeon will answer any questions before the anesthesia is administered. - Correct Answer Inform the surgeon that the operative permit is not signed and the client has questions about the surgery. 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 as possible? A.Daily black, sticky stool B.Daily dark brown stool C.Firm brown stool every other day D.Soft light brown stool twice a day - Correct Answer Daily black, sticky stool A male client is laughing at a television program with his wife when the evening nurse enters the room. He says his foot is hurting and he would like a pain pill. How should 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. - Correct Answer Ask him to rate his pain on a scale of 1 to 10. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best? A.Only refer to the client by gender. B. Identify the client only by age. C.Avoid using the client's name. D.Discuss the client another time. - Correct Answer Discuss the client another time. he nurse assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the nurse do next? A.Apply a warm compress proximal to the site. The nurse identifies a potential for infection in a client with partial-thickness (second- degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection? A.Administration of plasma expanders B.Use of careful handwashing technique C.Application of a topical antibacterial cream D.Limiting visitors to the client with burns - Correct Answer Use of careful handwashing technique The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A."At home | take my pills at 8:00 am." B."It costs a lot of money to buy all of these pills." C."| get so tired of taking pills every day." D."This is a new pill | have never taken before." - Correct Answer "This is a new pill | have never taken before." The nurse is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery? A.Taking birth control pills for the past 2 years B.Taking anticoagulants for the past year C.Recently completing antibiotic therapy D.Having taken laxatives PRN for the last 6 months - Correct Answer Taking anticoagulants for the past year A nurse is assigned to care for a close friend in the hospital setting. Which action should the nurse take first when given the assignment? A.Notify the friend that all medical information will be kept confidential. B.Explain the relationship to the charge nurse and ask for reassignment. C.Approach the client and ask if the assignment is uncomfortable. D.Accept the assignment but protect the client's confidentiality. - Correct Answer Explain the relationship to the charge nurse and ask for reassignment. The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom door, he states, "I feel faint." Before the nurse can get the client toa chair, the client starts to fall. Which is the priority action for the nurse to take? A.Check the client's carotid pulse. B.Encourage the client to get to the toilet. C.In a loud voice, call for help. D.Gently lower the client to the floor. - Correct Answer Gently lower the client to the floor. C."Compress the inhaler while inhaling quickly through your nose." D."Exhale completely after compressing the inhaler and then inhale." - Correct Answer Compress the inhaler while slowly breathing in through your mouth." The nurse is instructing a client with cholecystitis regarding diet choices. Which meal best meets the dietary needs of this client? A.Steak, baked beans, and a salad B.Broiled fish, green beans, and an apple C.Pork chops, macaroni and cheese, and grapes D.Avocado salad, milk, and angel food cake - Correct Answer Broiled fish, green beans, and an apple The nurse is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the nurse to implement? A.Stay with the client while the client is standing. B.Record the findings on the graphic sheet in the chart. C.Keep the blood pressure cuff on the same arm. D.Record changes in the client's pulse rate. - Correct Answer Stay with the client while the client is standing. The nurse is preparing an older client for discharge. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? A.Determine how the client feels about changing the dressing. B.Ask the client to describe the procedure in writing. C.Seek a family member's evaluation of the client's ability to change the dressing. D.Observe the client change the dressing unassisted. - Correct Answer Observe the client change the dressing unassisted. The nurse is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the nurse include in this procedure? A.Dilute each of the medications with sterile water prior to administration. B.Mix the medications in one syringe before opening the feeding tube. C.Administer water between the doses of the two liquid medications. D.Withdraw any fluid from the tube before instilling each medication. - Correct Answer Administer water between the doses of the two liquid medications. The nurse is teaching a client how to perform progressive muscle relaxation techniquesto relieve insomnia. A week later the client reports that he is still C.Place the client on seizure precautions for 24 hours. D.Report decorticate posturing to the health care provider - Correct Answer Document that the client responds to painful stimulus. A nurse is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck bed. The client is alert but reports feeling faint. Which assessment will the nurse perform first? A.Pulse characteristics B.Open airway C.Entrance and exit wounds D.Cervical spine injury - Correct Answer Pulse characteristics The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction? A.Perform range-of-motion exercises to prevent contractures. B.Decrease the client's fluid intake to prevent diarrhea. C.Massage the client's legs to reduce embolism occurrence. D.Turn the client from side to back every shift. - Correct Answer Perform range- of-motion exercises to prevent contractures. The nurse observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the nurse's intervention? A.The cuff wraps around the girth of the leg. B.The UAP auscultates the popliteal pulse with the cuff on the lower leg. C.The client is placed in a prone position. D.The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm - Correct Answer The UAP auscultates the popliteal pulse with the cuff on the lower leg. The nurse plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the nurse administer? (Round to the nearest tenth.) A. 0.2 mL B. 0.8 mL C. 1.25 mL D. 2.0 mL - Correct Answer 0.8 mL The nurse prepares to insert a nasogastric tube in a client with hyperemesis who is awake and alert. Which intervention(s) is(are) correct? (Select all that apply.) A.Place the client in a high Fowler position. B.Help the client assume a left side-lying position. C.Measure the tube from the tip of the nose to the umbilicus.