Fundamentals Hesi Review Questions

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1. The nurse is at a teen event. Which teen’s statement would cause the nurse to input some safety tips?(Select all that apply) A. “My boyfriend and I fool around on occasion, but he never comes... when he is inside me” B. “I hang around with my friends after the games, like football and baseball.” C. “I never work until 10:00 pm at a local fast-food restaurant.” D. “I never use my seatbelt while I am driving. I hate the way it feels.” E. “We often go and play beach volleyball when it is nice out.” A,D Sexual exploration is not uncommon as teen. However, pregnancy can occur with ejaculation on the perineal area. Accidents are the leading cause of death in the teen years and seatbelt use must be encouraged at all times. The remaining statements demonstrate normal growth and development for teen years. 2. The nurse is providing care to an 86-year-old admitted for a heart catheterization. The nurse determines the client does not have an advance directive (AD) on file. What are the nurse’s next steps? (Select all that apply.) A. Ask the client’s cardiologist to come to the hospital and obtain the AD. B. Ask the client, “Have you considered completing the paperwork for an AD?” C. Ask the client’s spouse to complete the AD. D. Tell the client, “An AD helps the staff provide care according to your wishes.” E. Call the client’s clergy member to make the final decisions for the client. B,D A living will is one type of advance directive. The living will outlines the medical treatment the client elects in the event that the client is no longer able to participate in the decisionmaking process. As long as the client has capacity, the client is the sole determinant for the AD. While a living will describes the wishes of the client, it does not have to be obtained from the physician. Clients may be assisted by the social work staff. The forms can be completed outside of a medical facility and it is the client’s responsibility to provide a copy of the AD to all health care providers. 3. Which action is most important for the nurse to include in the plan of care for a client at high risk for the development of postoperative thrombus formation? A. Instruct in the use of the incentive spirometer. B. Elevate the head of the bed during all meals. C. Use aseptic technique to change the dressing. D. Encourage frequent ambulation in the hallway D Thrombus (clot) formation can occur in the lower extremities of immobile clients, so the nurse should plan to encourage activities to increase mobility, such as frequent ambulation in the hallway. Option A helps promote alveolar expansion, reducing the risk for atelectasis. Option B reduces the risk for aspiration. Option C reduces the risk for postoperative infection.4. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order? A. “At home I take my pills at 8:00 am.” B. “It costs a lot of money to buy all of these pills.” C. “I get so tired of taking pills every day.” D. “This is a new pill I have never taken before.” D The client’s recognition of a “new” pill requires further assessment to verify that the medication is correct, if it is a new prescription or a different manufacturer, or if the client needs further instruction. The time difference may not be as significant in terms of its effect, but this should be explained. Although comments about cost should be considered when developing a discharge plan, option D is a higher priority. The client’s feelings C should be acknowledged, but observation of the five rights of medication administration is most essential. 5. The nurse is working at a community-based clinic. Which client’s spiritual wellbeing concerns the nurse the most? A. Roman Catholic woman considering an abortion B. Jewish man considering hospice care for his wife C. Seventh-Day Adventist who needs a blood transfusion D. Muslim man who needs a total knee replacement A In the Roman Catholic religion, any type of abortion is prohibited, so facing this decision may place the client at risk for spiritual distress. There is no prohibition of hospice care for members of the Jewish faith. Jehovah’s Witnesses, not Seventh-Day Adventists, prohibit blood transfusions. There is no conflict in the Muslim faith with regard to joint replacement. 6. The nurse observes a UAP taking a client’s blood pressure in the lower extremity. Which observation of this procedure requires the nurse to intervene with the UAP’s approach? A. The cuff wraps around the girth of the leg. B. The UAP auscultates the popliteal pulse with the cuff on the lower leg. C. The client is placed in a prone position. D. The systolic reading is 20 mm Hg higher than the blood pressure in the client’s arm. B When obtaining the blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. The nurse should intervene with the UAP who has applied the cuff on the lower leg. Option A ensures an accurate assessment, and option C provides the best access to the artery. Systolic pressure in the popliteal artery is usually 10 to 40 mm Hg higher than in the brachial artery.7. The nurse is providing care to a client immediately after a total right mastectomy. What steps will the nurse include when positioning the client? (Select all that apply.) A. Raise the head of the bed 30 to 45 degrees. B. Roll the client to her right side and place a pillow behind her back. C. Elevate her right arm under two pillows. D. Require the client to stay in bed for 72 hours post procedure. E. Place a sandbag on the incision. A,C The client must stay on her back or on the unaffected side, not on the operative side. Mobility as tolerated; there is no need to remain immobile. A sandbag is used when there is risk of bleeding from the wound. There is no mention of that risk in the stem. Sitting up and elevating the arm will help lymph drainage. 8. The nurse is planning care for a client with an indwelling urinary catheter. Which nursing action has the highest priority? A. Assist the client with daily cleansing. B. Tell the client that incontinence happens with aging. C. Offer 200 mL of fluid every 2 hours while awake. D. Take the client’s temperature every 4 hours. D Indwelling urinary catheters are a major source of infection. Option A is a problem that may develop from having an indwelling catheter. Option B may or may not be true for the client. Option C is not affected by an indwelling catheter. 9. The nurse is preparing to insert an IV, and cap off the IV with an intermittent infusion device for an 80-year-old who is prescribed IV antibiotics every 8 hours. The client is taking po fluids well. What supplies will the nurse take into the room for this procedure? (Select all that apply.) A. A 16 gauge IV catheter B. Normal saline in a 10 mL syringe C. Skin preparation antiseptic swab D. Clear plastic sterile bandage E. 1000 mL bag of normal saline B,C,D Items not needed to insert an IV for intermittent antibiotic therapy for an 80-year-old are a 16 gauge intracath; the intracath is too large. Large bore intracaths are for rapid infusions. A small bag of NS, e.g. 250 mL, will be needed to flush the line. The remaining items are needed to start an IV. [Show More]

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