HESI FUNDAMENTALS PRACTICE TEST

HESI FUNDAMENTALS PRACTICE TEST /

FINAL EXAM 1 (NCLEX)

A 35y/o 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.

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.

What client statement indicates to the nurse that the client requires assistance with bathing? - "I don't understand why I'm so weak & tired."

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

When caring for an immobile client, what nursing diagnosis has the highest priority? - Impaired gas exchange

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.

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

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

Medication is prescribed to be given QID. What schedule should the nurse use to administer this Rx? - 0800, 1200, 1600, 2000

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 55y/o 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.

A 4y/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."

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? - 1.Snack of potato chips & diet soda

• Lunch of tuna, carrots, fruit & coffee

• Breakfast of eggs, bacon, toast & coffee

• Bedtime snack of crackers & milk

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.

Male client with nursing diagnosis of "spiritual distress". What intervention is best for the nurse to implement when caring for this client? - Use reflective listening techniques when the client expresses spiritual doubts.

Rationale: Client should be consulted before involving chaplain.

Client with nursing diagnosis of "Spiritual distress r/t loss of hope secondary to impending death." What intervention is best for the nurse to implement when caring for this client? - Assist & support the client in establishing short-term goals.

Rationale: Hopefulness is necessary to sustain a meaningful existence, even close to death.

Nurse who puts meds in her uniform pocket to deliver to clients confides that after arriving home, she found a hydrocodone tablet in her pocket. Which possible

outcome of this situation should be the nurse's greatest concern? - Accused of diversion

A signed consent form indicated a client should have an electromyogram, by a myelogram was performed instead. Thought the myelogram revealed the cause of the client's back pain, the client filed a lawsuit against the nurse & HCP for performing the incorrect procedure. The court is likely to rule in favor of the plaintiff because these events represent which infraction? - Assault & battery with deliberate intent to deviate from the consent form

A 75y/o client who has a history of end stage renal failure & advancing lung cancer, recently had a stroke. 2 days ago, the HCP d/c the client's dialysis treatments, stating that death is inevitable, but the client is disoriented & will not sign a DNR directive. What is the priority nursing intervention? - Determine who is legally empowered to make decisions

The charge nurse assigns a nursing procedure to a new staff nurse who has not previously performed the procedure. What action is most important for the new staff nurse to take? - Refuse to perform the task that is beyond the nurse's experience

Rationale: According to states' nurse practice acts, it is the responsibility of the nurse to function within the scope of competency.

Before administering a client's medication, the nurse assesses a change in the client's condition & withholds the medication until consulting with the HCP. The dose is changed & the nurse administers the new Rx 1 hour later than originally scheduled. What action should the nurse implement in response to this situation? - Document the events that occurred in the nurses' notes.

On the third postoperative day following thoracic surgery, a client reports feeling constipated. Which intervention should the nurse implement to promote bowel elimination? - Provide warm prune juice before the client goes to bed at night

The home health nurse visits an elderly client who lives at home with her husband.She experiences frequent episodes of diarrhea & bowel incontinence. Which problem, for which the client is at risk, has the greatest priority when planning the client's care? - Fluid volume imbalance

A nurse observes a student nurse taking a copy of a client's medication administration record. What response should the nurse provide first? - Explain that the records are hospital property & may not be removed.

After a client has been premedicated for surgery with an opioid analgesic, the nurse discovers that the operative permit has not been signed. What action should the nurse implement? - Notify the surgeon that the consent form has not been signed

Rationale: Once a client has been premedicated for surgery with any type of

sedative, legal informed consent is not possible, so the nurse must notify the surgeon. Remaining options are not legally viable options for ensuring informed consent.

A client who has been on bedrest for several days now has a prescription to progress daily activity as tolerated. When nurse assists client out of bed for the first time, the client becomes dizzy. What action should the nurse implement? - Advise the client to sit on the side of the bed for a few minutes before standing again.

The charge nurse observes a UAP bending at the waist to lift a 20lb box. What instruction should the charge nurse provide? - Bend at the knees when lifting heavy objects

AN older client with RA is complaining of severe joint pain that is caused by weight of the linen on her legs. What action should the nurse implement first? - Drape the sheets over the footboard of the bed

A client is admitted to the hospital with intractable pain. What instruction should the nurse provide the UAP who is assisting with a bed bath? - Take measures to promote as much comfort as possible

A client arrives for scheduled needle aspiration. He tells the nurse he has already given verbal consent to the HCP. What action should the nurse implement? - Witness the client's signature on the consent form

In assessing a client's femoral pulse, the nurse must use deep palpation to feel the pulsation when the client is in supine position. What action should the nurse implement? - Document the presence & volume of the pulse palpated

A nurse is preparing to insert a rectal suppository & observes a small amount of rectal bleeding. What action should the nurse implement? - Withhold the administration of the suppository until contacting the HCP

The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique. What action should the nurse take after applying gloves? - Draw up the irrigating solution into the syringe.

Rationale: First apply gloves, then draw up the irrigating solution. Syringe is attached to catheter & fluid is instilled, using aseptic technique. Once instilled, catheter should be secured to drainage tubing. Drainage bag can be emptied whenever I&O measurement is indicated

When assessing a client with an indwelling urinary catheter, which observation requires the most immediate intervention by the nurse. - The clamp on the urinary drainage bag is open

While preparing to insert a rectal suppository into a male adult client, the nurse observes the client holding his breath while bearing down. What action should the nurse implement? - Instruct the client to take slow deep breaths & stop bearing down

The nurse is completing the care plan for a client who is admitted for BPH. Which data should the nurse document as a subjective finding? - Complains of inability to empty bladder