Fundamental of Nursing HESI ALL VERSIONS COVERED 2021

1- An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my

parent is always angry at me." The nurse's best initial response is "Your parent is:

Working through acceptance of the situation."

2- During the beginning phase of a therapeutic relationship, a clear understanding of participants'

roles is important because the client:

Needs to know what to expect from the relationship

3- The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to

be affected by aging?

Strategies to handle stress

4- What is the primary purpose of evidence-based nursing (EBP)?

Using results from research to improve the outcome of nursing care

5-

A high-protein diet is recommended for a client recovering from a fracture. The nurse recalls that the

rationale for a high-protein diet is to

Promote cell growth and bone union

6-

Nursing actions for the older adult should include health education and promotion of self-care. Which

is most important when working with the older adult client?

Reinforcing the client's strengths and promoting reminiscing

7-

A nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are

more obvious on inspiration. This assessment should be documented as:

Crackles

8-

A nurse hired to work in a metropolitan hospital provides services for a culturally diverse population.

One of the nurses on the unit says it is the nurses' responsibility to discourage "these people" from

bringing all that "home medicine stuff" to their family members. Which response by the recently hired

nurse is most appropriate?

You are right because they may have a negative impact on people's health.

9-

During a newborn assessment the nurse identifies that the temperature, pulse, respirations, and

other physical characteristics are within the expected range. The nurse records these findings on the

clinical record. Legally, how should the nurse's action be interpreted?

The nurse met the requirements set forth in the Nurse Practice Act.

10-

Which of the following legal defenses is the most important for a nurse to develop?

Accountability

11-

A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse

discovers that the client has received burns due to incorrect settings when the heating pad was

initiated. Which principle would legally apply?

The nurse could be held liable for the injury that occurred

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The plan of care for the client was to lose 7 pounds by the end of the month. The client only lost 3

pounds. The nurse should:

Reevaluate the plan of care for appropriateness.

13-

When caring for a client with venous insufficiency, the nurse would implement which nursing

measure?

Elevate the client's legs above heart level.

14-

A nurse is teaching a client about gentamycin (Garamycin) that has been prescribed for a severe

infection. Which statement indicates to the nurse that the client needs further teaching?

It is okay for me to stop taking this medication after a few days."\

15-

A nurse is assigned to change a central line dressing. The agency policy is to clean the site with

Betadine and then cleanse with alcohol. The nurse recently attended a conference that presented

information that alcohol should precede Betadine in a dressing change. In addition, an article in a

nursing journal stated that a new product was a more effective antibacterial than alcohol and

Betadine. The nurse has a sample of the new product. How Should the nurse proceed?

Follow the agency's policy unless it is contradicted by a health care provider's prescription.

16-

While the nurse moves a client from a lying to standing position, the client experiences a rapid drop in

blood pressure. The nurse would report this finding as:

Orthostatic hypotension

17-

A client experiences a muscle sprain of the ankle. When assessing the injury, the nurse discovers that

a hematoma is developing, edema is present and that the client reports tenderness when the ankle is

palpated. The nurse anticipates that the plan of care will include the application of a(n):

Ice bag18- The professional obligation of a nurse to assume responsibility for actions is referred to as:

Accountability

19-

The nurse prepares to give a prescribed capsule of hydroxyzine (Vistaril) to a client. The client begins

to vomit so the nurse holds the oral medication. The nurse has not opened the medication package.

Proper and safe disposal of the capsule of hydroxyzine requires the nurse to:

Return the capsule to the pharmacy

20-

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to

prevent what serious complication?

Aspiration pneumonia

21- The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The

nurse should monitor the results of which laboratory test to evaluate the client for hypoxia?

Arterial blood gas

22-

A client with a leg prosthesis and a history of syncopal episodes is being admitted to the hospital.

When formulating the plan of care for this client, the nurse should include that the client is at risk for:

Falls

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A 50-year-old client being seen for a routine physical asks why a stool specimen for occult blood

testing has been prescribed when there is no history of health problems. What is an appropriate

nursing response?

"It is performed routinely starting at your age as part of an assessment for colon cancer

24-

An adult child of a dying client says to the nurse in the nursing home, "I am so upset because my

parent is always angry at me." The nurse's best initial response is "Your parent is:

working through acceptance of the situation."

25-

A health care provider tells a client about the diagnosis of inoperable cancer and that the client does

not have long to live. After the health care provider leaves, the client says to the nurse, "I feel fine. I

probably only have the flu." The nurse determines that the client is in the denial stage of grief. What

should the nurse do to help meet the client's emotional needs?

Allow the denial and be available to discuss the situation with the client.

26-

The nurse has provided instructions about back safety to a client. Which client statement indicates

understanding of the instructions?

"I should carry objects close to my body."

27-

The nurse teaching a health awareness class identifies which situation as being the highest risk factor

for the development of a deep vein thrombosis (DVT)?

Inactivity

28-

A client is being admitted to a medical unit with a diagnosis of pulmonary tuberculosis. The nurse

should assign the client to which type of room?

Negative airflow room

29-

A nurse is reviewing a client's plan of care. What is the determining factor in the revision of the plan?

Effectiveness of the interventions

30-

A nurse who promotes freedom of choice for clients in decision-making best supports which

principle?

Autonomy

31-

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin

in the blood has what effect on oxygenation status?

A low hemoglobin level causes reduced oxygen-carrying capacity.

32-

A client with hypothermia is brought to the emergency department. What treatment does the nurse

anticipate?

Core rewarming with warm fluids

33-

A visitor says to the nurse, "Can I read my client's progress record? I am the sponsor from an alcohol

recovery program." How should the nurse respond?

Do not allow the sponsor to review the record.

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Two nurses are planning to help a client with one-sided weakness to move up in bed. What should the

nurses do to conform to a basic principle of body mechanics?

Position the nurses on either side of the bed with their feet apart, gather the pull sheet close to the

client, turn toward the head of the bed, and then move the client.

35-

In all states of the United States, what is the professional nurse's legal responsibility regarding child

abuse?

Report any suspected abuse to local law enforcement authorities.

36-

The hospital's policy requires two nurses to supervise the wasting of excess opioid solutions. The

nurse draws up the prescribed dose and then requests that another nurse witness wasting of the

remaining medication. The second nurse states that there is no time to observe the wasting of the

medication, enters the identification to serve as the witness, and leaves the area. What is the

appropriate action for the first nurse to take?

Cancel the process and ask another nurse to serve as the witness and to observe the wasting of the

medication.

37-

Nursing actions for the older adult should include health education and promotion of self-care. Which

is most important when working with the older adult client?

Reinforcing the client's strengths and promoting reminiscing

38-

The nurse is caring for a surgical client that develops a wound infection during hospitalization. How is

this type of infection classified?

Nosocomial

39-

A nurse applies a heating pad to a client's buttocks. Upon removal of the heating pad, the nurse

discovers that the client has received burns due to incorrect settings when the heating pad was

initiated. Which principle would legally apply?

The nurse could be held liable for the injury that occurred

40-

A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of

the illness. Behaviors that indicate the client is emotionally accepting of impending death are that the

client is:

Revising the client's will and planning a visit to a friend

41-

A 2-year-old child admitted with a diagnosis of pneumonia was administered antibiotics, fluids, and

oxygen. The child's temperature increased until it reached 103° F. When notified, the health care

provider determined that there was no need to change treatment, even though the child had a

history of febrile seizures. Although concerned, the nurse took no further action. Later, the child had a

seizure that resulted in neurologic impairment. Legally, who is responsible for the child's injury?

Nurse, because failure to further question the health care provider about the child's status placed the

child at risk

42-

The nurse is monitoring a client's hemoglobin level. The nurse recalls that the amount of hemoglobin

in the

blood has what effect on oxygenation status?

A low hemoglobin level causes reduced oxygen-carrying capacity.

43-

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