HESI - Fundamentals Practice Questions Correct and Verified Answers Graded A

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HESI - Fundamentals Practice Questions Correct and Verified Answers Graded A

• While reviewing the side effects of a newly prescribed medication, a 72-year-old

client notes that one of the side effects is a reduction in sexual drive. Which is the best response by the nurse?

• "How will this affect your present sexual activity?"
• "How active is your current sex life?"
• "How has your sex life changed as you have become older?"
• "Tell me about your sexual needs as an older adult."

Correct Answer: A

Rationale: Option A offers an open-ended question most relevant to the client's

statement. Option B does not offer the client the opportunity to express concerns. Options C and D are even less relevant to the client's statement.

• 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?

• Taking birth control pills for the past 2 years
• Taking anticoagulants for the past year
• Recently completing antibiotic therapy
• Having taken laxatives PRN for the last 6 months

Correct Answer: B

Rationale: Anticoagulants increase the risk for bleeding during surgery, which can pose a threat for the development of surgical complications. The health care provider should be informed that the client is taking these drugs. Although clients who take birth control pills may be more susceptible to the development of thrombi, such problems usually occur postoperatively. A client with option C or D is at less of a surgical risk than with option B.

• When turning an immobile bedridden client without assistance, which action by the

nurse best ensures client safety?

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• Securely grasp the client's arm and leg.
• Put bed rails up on the side of bed opposite from the nurse.
• Correctly position and use a turn sheet.
• Lower the head of the client's bed slowly.

Correct Answer: B

Rationale: Because the nurse can only stand on one side of the bed, bed rails should be up on the opposite side to ensure that the client does not fall out of bed. Option A can cause client injury to the skin or joint. Options C and D are useful techniques while turning a client but have less priority in terms of safety than use of the bed rails.

• The nurse is instructing a client in the proper use of a metered-dose inhaler. Which

instruction should the nurse provide the client to ensure the optimal benefits from the drug?

• "Fill your lungs with air through your mouth and then compress the inhaler."
• "Compress the inhaler while slowly breathing in through your mouth."
• "Compress the inhaler while inhaling quickly through your nose."
• "Exhale completely after compressing the inhaler and then inhale."

Correct Answer: B

Rationale: The medication should be inhaled through the mouth simultaneously with compression of the inhaler. This will facilitate the desired destination of the aerosol medication deep in the lungs for an optimal bronchodilation effect. Options A, C, and D do not allow for deep lung penetration.

• The nurse is aware that malnutrition is a common problem among clients served by

a community health clinic for the homeless. Which laboratory value is the most reliable indicator of chronic protein malnutrition?

• Low serum albumin level
• Low serum transferrin level
• High hemoglobin level
• High cholesterol level

Correct Answer: A

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Rationale: Long-term protein deficiency is required to cause significantly lowered serum albumin levels. Albumin is made by the liver only when adequate amounts of amino acids (from protein breakdown) are available. Albumin has a long half-life, so acute protein loss does not significantly alter serum levels. Option B is a serum protein with a half-life of only

• to 10 days, so it will drop with an acute protein deficiency. Options C and D are not

clinical measures of protein malnutrition.

• Which step(s) should the nurse take when administering ear drops to an adult

client? (Select all that apply.)

• Place the client in a side-lying position.
• Pull the auricle upward and outward.
• Hold the dropper 6 cm above the ear canal.
• Place a cotton ball into the inner canal.
• Pull the auricle down and back.

Correct Answer: A, B

Rationale: The correct answers (A and B) are the appropriate administration of ear drops.The dropper should be held 1 cm (½ inch) above the ear canal (C). A cotton ball should be placed in the outermost canal (D). The auricle is pulled down and back for a child younger than 3 years of age, but not an adult (E).

• 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?

• Administration of plasma expanders
• Use of careful handwashing technique
• Application of a topical antibacterial cream
• Limiting visitors to the client with burns

Correct Answer: B

Rationale: Careful handwashing technique is the single most effective intervention for the prevention of contamination to all clients. Option A reverses the hypovolemia that initially accompanies burn trauma but is not related to decreasing the proliferation of infective organisms. Options C and D are recommended by various burn centers as possible ways to reduce the chance of infection. Option B is a proven technique to prevent infection.

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• A 20-year-old female client with a noticeable body odor has refused to shower for

the last 3 days. She states, "I have been told that it is harmful to bathe during my period." Which action should the nurse take first?

• Accept and document the client's wish to refrain from bathing.
• Offer to give the client a bed bath, avoiding the perineal area.
• Obtain written brochures about menstruation to give to the client.
• Teach the importance of personal hygiene during menstruation with the client.

Correct Answer: D

Rationale: Because a shower is most beneficial for the client in terms of hygiene, the client should 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.

• In completing a client's preoperative routine, the nurse finds that the operative

permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?

• Witness the client's signature to the permit.
• Answer the client's questions about the surgery.
• Inform the surgeon that the operative permit is not signed and the client has questions

about the surgery.

• Reassure the client that the surgeon will answer any questions before the anesthesia is

administered.

Correct Answer: C

Rationale: The surgeon should be informed immediately that the permit is not signed. It is the surgeon's responsibility to explain the procedure to the client and obtain the client's signature on the permit. Although the nurse can witness an operative permit, the procedure must first be explained 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.

• When assisting a client from the bed to a chair, which procedure is best for the

nurse to follow?

• Place the chair parallel to the bed, with its back toward the head of the bed and assist

the client in moving to the chair.