HESI FUNDAMENTALS RN STUDY GUIDE TEST BANK

Q/A(S)

1. Wheezing is often associated with asthma- assess breathing patterns and learn about any

precipitating factors that caused the onset of the wheezing

2. A male client with limited mobility is discharged with home health services. When the

home health nurse arrives, the client asks what he does for the swelling in his leg. Which

should the nurse implement?

✔ -instruct the client to flex both of his feet several times a day

3. A client at an outpatient clinic submits a clean-catch midstream urine specimen for a

routine urinalysis. In later review of the client’s medical record, which data indicates to

the nurse that the specimen collection should be repeated?

✔ -the urine specimen shows multiple organisms in low colony counts

Rationale: *often indicates that a contaminated specimen was obtained

4. During the admission assessment of a terminally ill male client, the client states that he

is an agnostic. What is the best nursing action in response to this statement?

✔ -document the statement in the client’s spiritual assessment

5. The nurse observes a newly admitted older adult female take short stems and walk very

slowly while pushing a walker in front of her. What action should the nurse take in

response to these observations?

✔ -complete a full fall risk assessment of the client

6. The nurse notes that a client has cyanosis of the toes and fingertips. Which vital signs

should the nurse obtain first?

✔ -respiratory rate

Rationale: *cyanosis is a bluish discoloration, an indication of

hypoxemia

7. A middle-aged male client tells the nurse that two weeks ago he began exercising four

times a week to lose weight and to help him sleep better. He states that it still takes him

an hour to fall asleep at night. Which action should the nurse implement?

✔ -ask the client to describe the exercise schedule that he has been

following

Rationale: *to determine if he is exercising too close to bedtime

8. While suctioning a client's nasopharynx, the nurse observes that the patient's oxygen

saturation remains at 94%, which is the same reading obtained prior to starting the

procedure. What action should the nurse take in response to this finding?

✔ -complete the intermittent suction of nasopharynx *suctioning can be

continued if the client’s oxygen saturation remains above 90% or

does not decrease 5% from the initial baseline 

9. An older male client returns to the clinic for chronic pain management after taking

morphine sulfate (MS Contin) 25 mg every 12 hours. He states he took the medication

only when the pain was too severe to sleep. What action should the nurse implement?

✔ -instruct the client to take the MS Contin every 12 hours as prescribed

10.A female unlicensed assistive personnel (UAP) is assigned to take the vital signs of a

client with pertussis for whom droplet precautions have been implemented. The UAP

requests a change in assignment, stating she has not yet been fitted for a particulate filter

mask. What action should the nurse take first?

✔ -instruct the UAP that a standard face mask is sufficient for the

provision

of care for the assigned client

Rationale: *a particulate filter mask is indicated for clients with

airborne precautions

11.The community health nurse is making a home visit when the client, who is sitting at the

kitchen table, begins to have a seizure. What action should the nurse take first?

✔ -assist the client to the floor

12.A client is in contact isolation due to a stage IV coccyx wound infected with

methicillin resistant staphylococcus aureus (MRSA). The nurse plans

interventions to prevent multiple re-entries to the client’s room. In

which order should the nurse perform the interventions?

✔ -restart the IV, perform tracheostomy care, change the coccyx dressing

13.A client who has been taking diuretics for premenstrual swelling reports muscle

weakness. Which serum electrolyte value should the nurse report to the healthcare

provider?

✔ -Potassium 3.1 mEq/L (3.1 mmol/L)

14.A client diagnosed with primary open-angle glaucoma received a prescription for miotic

eye drops, pilocarpine HCl (Pilocarpine). What instructions should the nurse plan to

include in the client’s teaching?

✔ - “do not allow the dropper bottle to touch the eye”

15.*Sleeping side

✔ lying with hips and knees flexed prevents unnecessary pressure on

support muscles, ligaments, and lumbosacral joints and reduces low

back pain

16.*Obesity

✔ a BMI greater than 30

17.*Hygiene self-care deficit

✔ evaluate the client’s participation in self-care to optimal level of

capacity is the best goal to evaluate progress in recovery 

18.The unlicensed assistive personnel (UAP) describes the appearance of the bowel

movement s of several clients. Which descriptions warrant additional follow-up by

the nurse?

✔ -multiple hard pellets, tarry appearance, and brown liquid

19.A client with a gastronomy tube is recovering a continuous feeding, and the nurse

suspects that the client has aspirated some of the feeding. What is the action by the

nurse?

✔ -stop the tube feeding and assess the client

20.*it is the best response for the nurse to provide a response that reflects what the client

stated and confirms their condition is serious.

21.The nurse is caring for a male client with diminished circulation in the lower extremities.

The client washes his feet in the shower, but is unable to bend safely to dry his feet.

While drying the client’s feet, the nurse should emphasize the need to thoroughly dry

which area of the feet?

✔ -between the toes

22.When performing blood pressure measurement to assess for orthostatic

hypotension, which action should the nurse implement first?

✔ -position the client supine for a few minutes

23.A client who lives in an assisted living facility develops cognitive impairment

following a stroke. Informed consent is needed to provide additional nursing

services. Who should the nurse contact?

✔ -a daughter-in-law designated as the client’s Durable Power of

Attorney

(DPOA)

24.A 24-hour urine specimen is being collected for analysis of creatinine clearance. After

explaining the procedure, the client tells the nurse that the first sample is in the urinal.

When discarding this specimen, what action should the nurse take?

✔ -check the sample’s pH and specific gravity

25.A client has begun a long-term maintenance therapy with lithium, which has a narrow

therapeutic index. Which adverse effect is most important for nurse to include in the

teaching plan?

✔ -toxicity

26.A postoperative client has three different PRN analgesics prescribed for different levels

of pain. The nurse inadvertently administers a dose that is not within the prescribed

parameters. What action should the nurse take first?

✔ -assess for side effects/adverse effects of the medication

27.Which landmarks are useful to the nurse when administering an intramuscular injection

in the ventrogluteal site?

✔ -the greater trochanter and anterior superior iliac spine 

28.To assess the quality of an adult client’s pain, what approach should the nurse use?

✔ -ask the client to describe the pain

29.The home health nurse is reviewing the personal care needs of an elderly client who

lives alone. Which client assessment findings indicate the need to assign an unlicensed

assistive personnel (UAP) to provide routine foot care and file the client’s toenails?

(Select all that apply)

✔ -diminished visual activity

✔ syncope (dizziness) when bending

✔ hand tremors

30.The nurse measures the client’s blood pressure (PB) and notes that it is significantly

higher than the previous reading. What should the nurse do next? (Select all that

apply)

✔ -retake the client’s blood pressure in the opposite arm, determine the

client’s activity and feeling prior to the BP measurement

31.A male Native American presents to the clinic with complaints of frequent abdominal

cramping and nausea. He states that he has chronic constipation and had not had a bowel

movement in five days, despite trying several home remedies. Which intervention is

most important for the nurse to implement?

✔ assess for the presence of an impaction

Rationale: *it is common for cultures, such as Native Americans, to

believe in using home remedies and herbs before seeking medical

attention. The herbal remedies used for constipation and nausea

32.A client is admitted with pneumonia and has a recent history of

methicillin-resistant Staphylococcus aureus (MRSA). The client is

placed in isolation. While caring for the client, which item should the

nurse place in a designated biohazard bag before it is removed from

the room?

✔ -paper mask and gown

33.The home care nurse is teaching a client how to change the dressing on a new venous

stasis ulcer. The client has a history of deep vein thrombosis and is allergic to latex.

When removing the adhesive bandages, the nurse observes skin redness surrounding the

dressing wound. What action should the nurse

implement?

✔ -replace dressing with cotton pads and silk tape

Rationale: *the skin redness surrounding the wound may be due to

latex in the adhesive bandages, so the bandage should be replaced with

non-latex dressing, such as cotton pads and silk tape. A culture is not

indicated. A topical antibiotic ointment may be used if the wound

appears infected, but is not indicated for inflammatory redness created 

by the latex dressing. 

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