HESI FUNDAMENTALS PRACTICE EXAM 1. QUESTIONS AND ANSWERS.

HESI FUNDAMENTALS
PRACTICE EXAM 1

1. A 35 year old client with cancer refuses to allow a nurse to insert an IV for scheduled
   chemo & states that she’s ready to go home to die. What intervention should the nurse
   initiate?
   Evaluate the client’s mental status for competence to refuse treatment
   Rationale:
   Competent clients have the right to refuse treatment. The nurse cannot document until
   the HCP is notified of the patient’s wishes & a d/c RX is obtained. Advance directives &
   DNR are not necessary for competent client to refuse care.
2. A client with chronic renal disease is admitted to the hospital for evaluation prior to a
   surgical procedure. Which laboratory test indicates client’s protein status for the longest
   length of time?
   Serum albumin
   Rationale:
   Serum albumin has a long half-life.
3. What client statement indicates to the nurse that the client requires assistance with
   bathing?
   “I don’t understand why I’m so weak & tired.”
4. How should the nurse handle linens that are soiled with incontinent feces?
   Place the soiled linens in a pillow case & deposit them in the dirty linen hamper
5. When caring for an immobile client, what nursing diagnosis has the highest priority?
   Impaired gas exchange
6. The nurse assesses an immobile, elderly male client & determines that his blood
   pressure is 138/60, his temperature is 95.8F & his output is 100 mL of concentrated
   urine during the last hour. He has wet sounding lungs & increased respiratory
   secretions. Based on these assessment findings , what nursing action is most important
   for the nurse to implement?
   Turn the client q2h
   Rationale:
   It will help move & drain respiratory secretions & prevent pneumonia from occurring.
7. The home health nurse visits an elderly female client who had a brain attack 3
   months ago & is now able to ambulate with the assistance of a quad cane. Which
   assessment finding has the greatest implications for this client’s care?
   The nurse notes there are numerous scatter rugs throughout the house
8. The nurse removes the dressing on a client’s heel that is cover a pressure sore 1″ in
   diameter & finds that there is straw-colored drainage seeping from the wound. What
   description of this finding should the nurse include in the client’s record?
   One-inch pressure sore draining serous fluid
9. Medication is prescribed to be given QID. What schedule should the nurse use to
   administer this Rx?
   0800, 1200, 1600, 2000
10. The nurse working in the ED is assessing 4 clients’ ability to tolerate pain. Which
    client is likely to tolerate a higher level of pain?
    1 55year old woman who has had moderate low back pain for 3 months

Rationale:
Experiences with the same type of pain that has successfully been relieved makes it
easier for the client to interpret the pain sensation and, as a result, the client is better
prepared to take steps to relieve the pain. All other clients are having new experiences
with pain.

11. A 4year o boy who is scheduled for a tonsillectomy & adenoidectomy asks the
    nurse, “Will it hurt to have my tonsils & adenoids taken out?” Which response is best for
    the nurse to provide?
    “It may hurt, but we’ll give you medicine to help you feel better.”
12. A low-sodium, low-protein diet is prescribed for a 45y/o client with renal insufficiency
    & HTN, who gained 3lbs in the last month. The nurse determines that the client has
    been noncompliant with the diet, based on which report from the 24hr diet recall?
13. Snack of potato chips & diet soda
14. Lunch of tuna, carrots, fruit & coffee
15. Breakfast of eggs, bacon, toast & coffee
16. Bedtime snack of crackers & milk
17. What intervention should the nurse include in the care plan for a client who is being
    treated with an Unna’s paste boot for leg ulcers due to chronic venous insufficiency?
    Check capillary refill of toes on lower extremity with Unna’s paste boot
    Rationale:
    Boot becomes rigid after it dries, so it is important to check distally for adequate
    circulation. No bandage should be put under it. Should be applied from foot & wrapped
    towards knee. Acts as a sterile dressing & should not be removed q8h. Weekly removal
    is reasonable.
18. Male client with nursing diagnosis of “spiritual distress”. What intervention is best for
    the nurse to implement when caring for this client?