HESI FUNDAMENTALS V1
- A policy requiring the removal of acrylic nails by all nursing personnel was
implemented 6 months ago. Which assessment measure best determines if the
intended outcome of the policy is being achieved?
a. Number of staff induced injury
b. Client satisfaction survey
c. Health care-associated infection rate.
d. Rate of needle-stick injuries by nurse.
Rationale:
Acrylic nails are known to carry loads of bacteria and increase the risk of healthcareassociated infections. Therefore, by banning the wearing of acrylic nails, you would
expect the prevalence of healthcare-associated infections to decrease. Acrylic nails
have nothing to do with staff induced injuries, needle-stick injuries, or patient
satisfaction scores. - Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
-This is a method used to determine proper placement of NG tubing, but not the most
accurate.
B) Hearing air pass in the stomach after injecting air into the tubing.
-This is a method used to determine proper placement of NG tubing, but not the most
accurate.
C) Examining a chest x-ray obtained after the tubing was inserted.
-After placing an NG-tube, the placement of the tube is confirmed via x-ray since it is the
most accurate way to ensure the tube has not been placed in the lungs, which would
pose an aspiration risk.
D) Checking the remaining length of tubing to ensure that the correct length was
inserted.
-This is not an indicator of proper placement. You could very well be in a lung.
- The father of an 11-year-old client reports to the nurse that the client has been
“wetting the bed” since the passing of his mother and is concerned. Which action is
most important for the nurse to enact?
A. Reassure the father that it is normal for a pre-teen to wet the bed during puberty
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B. Inform the father that nocturnal emissions are abnormal and his son is
developmentally delayed
C. Inform the father that it is most important to let the son know that nocturnal emissions
are normal after trauma
D. Refer the father and the client to a psychologist
Rationale:
It is common for adolescents to regress in their biological progression after experiencing
a severe trauma, like losing a parent, sibling, or friend. While uncomfortable for the
adolescent and parent, it is nothing to be concerned for. Often times, as the patient
grieves or comes to terms with the trauma, the nocturnal emissions will cease. - The nurse explains to an older adult male the procedure for collecting a 24-hour urine
specimen for creatinine clearance. Which action is most important for the nurse to
include in their care plan for the shift?
A. Assess the client for confusion and reteach the procedure
B. Check the urine for color and texture
C. Empty the urinal contents into the 24-hour collection container
D. Discard the contents of the urinal
Rationale:
An “older adult male” in the question may imply that the patient may have an altered
mental status or be demented. While suggesting, it is not directly stated, therefore (A) is
inappropriate. (B) is incorrect because the lab will be assessing the collection specimen
after the test is complete. (C) is correct because the nurse should first discard the first
specimen, then begin to collect and record the time the first urine specimen was
collected. It is important to have strict documentation for output, and to collect every
urine specimen within that 24 hour period, otherwise the test must be restarted. (D)
defeats the purpose of the 24-hour urine collection test.
- A 54-year-old male client and his wife were informed this morning that he has
terminal cancer. Which nursing intervention is likely to most beneficial?
A. Ask her how she would like to participate in the client’s care.
B. Provide the wife with information about hospice
C. Encourage the wife to visit after painful treatments are completed
D. Refer her to support group for family members of those dying of cancer
Rationale:
While the client’s wife may be grieving and need support, the priority for the client and
client’s wife is to make sure the wife feels comfortable participating in the client’s care, if
at all. Most people have an easier time coming to terms with the death of a loved one
when they are involved in their care. (D) is a nice gesture, but will be more appropriate
at a later time. - A client who has a body mass index (BMI) of 30 is requesting information on the
initial approach to a weight loss plan. Which action should the nurse recommend first?
A. Plan low carbohydrate and high protein meals
B. Engage in strenuous activity for an hour daily
C. Keep a record of food and drinks consumed daily
D. Participated in a group exercise class 3 times a week
Rationale: