NURSING 201 - KEY FUNDAMENTALS SKILLS HESI EXAM (2019/20)

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NURSING 201 - KEY FUNDAMENTALS SKILLS HESI EXAM 1. 1.ID: An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care? 2. 2.ID: The... nurse is administering medications through a nasogastric tube (NGT) which is connected to suction. After ensuring correct tube placement, what action should the nurse take next? 3. 3.ID: A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement? 4. 4.ID: When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first? 5. 5.ID: The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein? 6. 6.ID: A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement? 7. 7.ID: While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement? 8. 8.ID: What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults? 9. 9.ID: The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement? 10. 10.ID: A client is receiving a secondary infusion of a 300 mg dose medication q6 hour. The preparation arrives from the pharmacy diluted in 50 mL of 0.9% Sodium Chloride (NaCl). The nurse plans to administer the dose over 20 minutes. For how many mL/hour should the nurse program the infusion pump to deliver the secondary infusion? (Enter the numeric value only.) 11. 11.ID: Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse? 12. 12.ID: The nurse is instructing a client with high cholesterol about diet and life style modification. What comment from the client indicates that the teaching has been effective? 13. 13.ID: The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client? 14. 14.ID: An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP? 15. 15.ID: A client who is a Jehovah’s Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client’s beliefs? 16. 16.ID: The nurse observes that a male client has removed the covering from an ice pack applied to his knee. What action should the nurse take first? 17. 17.ID: The nurse mixes 50 mg of Nipride in 250 ml of D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive? 18. 18.ID: A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take? 19. 19.ID: A male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. Since, at the time of discharge, timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow? 20. 20.ID: A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump? 21. 21.ID: An obese male client discusses with the nurse his plans to begin a long-term weight loss regimen. In addition to dietary changes, he plans to begin an intensive aerobic exercise program 3 to 4 times a week and to take stress management classes. After praising the client for his decision, which instruction is most important for the nurse to provide? 22. 22.ID: The nurse is teaching a client proper use of an inhaler. When should the client administer the inhaler-delivered medication to demonstrate correct use of the inhaler? 23. 23.ID: The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available in 5 mg tablets. How much should the nurse plan to administer? 24. 24.ID: The healthcare provider prescribes furosemide (Lasix) 15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters should the nurse administer? 25. 25.ID: Heparin 20,000 units in 500 ml D5W at 50 ml/hour has been infusing for 5½ hours. How much heparin has the client received? 26. 26.ID: The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? 27. 27.ID: The nurse prepares a 1,000 ml IV of 5% dextrose and water to be infused over 8 hours. The infusion set delivers 10 drops per milliliter. The nurse should regulate the IV to administer approximately how many drops per minute? 28. 28.ID: Which action is most important for the nurse to implement when donning sterile gloves? 29. 29.ID: A client’s infusion of normal saline infiltrated earlier today, and approximately 500 ml of saline infused into the subcutaneous tissue. The client is now complaining of excruciating arm pain and demanding “stronger pain medications.” What initial action is most important for the nurse to take? 30. 30.ID: An elderly male client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral feedings though a gastrostomy tube. What is the best client position for administration of the bolus tube feedings? 31. 31.ID: A 73-year-old female client had a hemiarthroplasty of the left hip yesterday due to a fracture resulting from a fall. In reviewing hip precautions with the client, which instruction should the nurse include in this client's teaching plan? 32. 32.ID: A client with pneumonia has a decrease in oxygen saturation from 94% to 88% while ambulating. Based on these findings, which intervention should the nurse implement first? 33. 33.ID: A client with chronic renal failure selects a scrambled egg for his breakfast. What action should the nurse take? 34. 34.ID: A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What question is most important for the nurse to include during the preoperative assessment? 35. 35.ID: During the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber. Which intervention should the nurse implement? 36. 36.ID: Which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention? 37. 37.ID: A client with acute hemorrhagic anemia is to receive four units of packed RBCs (red blood cells) as rapidly as possible. Which intervention is most important for the nurse to implement? 38. 38.ID: Which snack food is best for the nurse to provide a client with myasthenia gravis who is at risk for altered nutritional status? 39. 39.ID: The nurse is evaluating client learning about a low-sodium diet. Selection of which meal would indicate to the nurse that this client understands the dietary restrictions? 40. 40.ID: Which nutritional assessment data should the nurse collect to best reflect total muscle mass in an adolescent? 41. 41.ID: An elderly resident of a long-term care facility is no longer able to perform self-care and is becoming progressively weaker. The resident previously requested that no resuscitative efforts be performed, and the family requests hospice care. What action should the nurse implement first? 42. 42.ID: After completing an assessment and determining that a client has a problem, which action should the nurse perform next? 43. 43.ID: An elderly client who requires frequent monitoring fell and fractured a hip. Which nurse is at greatest risk for a malpractice judgment? 44. 44.ID: A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge? The client 45. 45.ID: When evaluating a client's plan of care, the nurse determines that a desired outcome was not achieved. Which action will the nurse implement first? 46. 46.ID: The healthcare provider prescribes 1,000 ml of Ringer's Lactate with 30 Units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min? 47. 47.ID: Seconal 0.1 gram PRN at bedtime is prescribed to a client for rest. The scored tablets are labeled grain 1.5 per tablet. How many tablets should the nurse plan to administer? 48. 48.ID: Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube? 49. 49.ID: The nurse is caring for a client who is receiving 24-hour total parenteral nutrition (TPN) via a central line at 54 ml/hr. When initially assessing the client, the nurse notes that the TPN solution has run out and the next TPN solution is not available. What immediate action should the nurse take? 50. 50.ID: When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the center of gravity for an elderly person is the 51. 51.ID: In developing a plan of care for a client with dementia, the nurse should remember that confusion in the elderly 52. 52.ID: An elderly male client who suffered a cerebral vascular accident is receiving tube feedings via a gastrostomy tube. The nurse knows that the best position for this client during administration of the feedings is 53. 53.ID: The nurse notices that the mother a 9-year-old Vietnamese child always looks at the floor when she talks to the nurse. What action should the nurse take? 54. 54.ID: When conducting an admission assessment, the nurse should ask the client about the use of complimentary healing practices. Which statement is accurate regarding the use of these practices? 55. 55.ID: A young mother of three children complains of increased anxiety during her annual physical exam. What information should the nurse obtain first? 56. 56.ID: Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse? 57. 57.ID: At the time of the first dressing change, the client refuses to look at her mastectomy incision. The nurse tells the client that the incision is healing well, but the client refuses to talk about it. What would be an appropriate response to this client's silence? 58. 58.ID: The nurse witnesses the signature of a client who has signed an informed consent. Which statement best explains this nursing responsibility? 59. 59.ID: The nurse assigns a UAP to obtain vital signs from a very anxious client. What instructions should the nurse give the UAP? 60. 60.ID: An adult male client with a history of hypertension tells the nurse that he is tired of taking antihypertensive medications and is going to try spiritual meditation instead. What should be the nurse's first response? 61. 61.ID: Examination of a client complaining of itching on his right arm reveals a rash made up of multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should the nurse record this finding? 62. 62.ID: The nurse is completing a mental assessment for a client who is demonstrating slow thought processes, personality changes, and emotional lability. Which area of the brain controls these neuro-cognitive functions? 63. 63.ID: A male client tells the nurse that he does not know where he is or what year it is. What data should the nurse document that is most accurate? 64. 64.ID: An IV infusion terbutaline sulfate 5 mg in 500 ml of D5W, is infusing at a rate of 30 mcg/min prescribed for a client in premature labor. How many ml/hr should the nurse set the infusion pump? 65. 65.ID: An African-American grandmother tells the nurse that her 4-year-old grandson is suffering with "miseries." Based on this statement, which focused assessment should the nurse conduct? 66. 66.ID: The nurse notices that the Hispanic parents of a toddler who returns from surgery offer the child only the broth that comes on the clear liquid tray. Other liquids, including gelatin, popsicles, and juices, remain untouched. What explanation is most appropriate for this behavior? 67. 67.ID: A client is receiving a cephalosporin antibiotic IV and complains of pain and irritation at the infusion site. The nurse observes erythema, swelling, and a red streak along the vessel above the IV access site. Which action should the nurse take at this time? 68. 68.ID: The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for fifteen seconds, large amounts of thick yellow secretions return. What action should the nurse implement next? 69. 69.ID: A female client with a nasogastric tube attached to low suction states that she is nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first? 70. 70.ID: During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a goniometer. Which finding should the nurse expect to measure? 71. 71.ID: During a physical assessment, a female client begins to cry. Which action is best for the nurse to take? 72. 72.ID: A female client asks the nurse to find someone who can translate into her native language her concerns about a treatment. Which action should the nurse take? 73. 73.ID: The nurse is teaching a client with numerous allergies how to avoid allergens. Which instruction should be included in this teaching plan? 74. 74.ID: On admission, a client presents a signed living will that includes a Do Not Resuscitate (DNR) prescription. When the client stops breathing, the nurse performs cardiopulmonary resuscitation (CPR) and successfully revives the client. What legal issues could be brought against the nurse? 75. 75.ID: A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse, "I don't want any more blood taken for those useless tests." Which narrative documentation should the nurse enter in the client's medical record? 76. 76.ID: At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care unit (PACU). When should the nurse document the client's findings? 77. 77.ID: An Arab-American woman, who is a devout traditional Muslim, lives with her married son's family, which includes several adult children and their children. What is the best plan to obtain consent for surgery for this client? 78. 78.ID: Which response by a client with a nursing diagnosis of Spiritual distress, indicates to the nurse that a desired outcome measure has been met? 79. 79.ID: During shift change report, the nurse receives report that a client has abnormal heart sounds. Which placement of the stethoscope should the nurse use to hear the client's heart sounds? 80. 80.ID: A nurse is preparing to give medications through a nasogastric feeding tube. Which nursing action should prevent complications during administration? 81. 81.ID: During the admission interview, which technique is most efficient for the nurse to use when obtaining information about signs and symptoms of a client's primary health problem? 82. 82.ID: An older client who is a resident in a long term care facility has been bedridden for a week. Which finding should the nurse identify as a client risk factor for pressure ulcers? 83. 83.ID: A client who has been NPO for 3 days is receiving an infusion of D5W 0.45 normal saline (NS) with potassium chloride (KCl) 20 mEq at 83 ml/hour. The client's eight-hour urine output is 400 ml, blood urea nitrogen (BUN) is 15 mg/dl, lungs are clear bilaterally, serum glucose is 120 mg/dl, and the serum potassium is 3.7 mEq/L. Which action is most important for the nurse to implement? 84. 84.ID: What action should the nurse implement when accessing an implanted infusion port for a client who receives long term IV medications? 85. 85.ID: During the daily nursing assessment, a client begins to cry and states that the majority of family and friends have stopped calling and visiting. What action should the nurse take? 86. 86.ID: The nurse plans to obtain health assessment information from a primary source. Which option is a primary source for the completion of the health assessment? 87. 87.ID: The nurse is using a genogram while conducting a client's health assessment and past medical history. What information should the genogram provide? [Show More]

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