HESI Fundamentals Practice Test

HESI Fundamentals Practice Test Related

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A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client's daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?

  • A. Refer to the risk manager
  • B. Notify the healthcare provider
  • C. Discontinue the ventilator
  • D. Review the medical record
Correct Answer: B

Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.

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While suctioning a client's nasopharynx, the nurse observes that the client'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?

  • A. Complete the intermittent suction of the nasopharynx.
  • B. Reposition the pulse oximeter clip to obtain a new reading.
  • C. Stop suctioning until the pulse oximeter reading is above 95%.
  • D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: A

Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation. Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable. Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%. Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.

After surgery, a client who had a colostomy says 'I know the doctor did not really do a colostomy'. The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery. What nursing action is indicated at this time?

  • A. Agree with the client until they are ready to accept the colostomy.
  • B. Say 'It must be difficult to have this kind of surgery'.
  • C. Force the client to look at their colostomy.
  • D. Ask the surgeon to explain the surgery to the client.
Correct Answer: B

Rationale: Acknowledging the client's feelings with empathy is essential in the early stage of adjustment to a colostomy surgery. By saying 'It must be difficult to have this kind of surgery,' the nurse validates the client's emotions and opens up a channel for further communication. Choice A is incorrect because agreeing with the client's denial is not therapeutic and may hinder acceptance. Choice C is inappropriate as it disregards the client's emotional state and autonomy. Choice D involves the surgeon and is not the nurse's role in addressing the client's emotional needs.

Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?

  • A. Monitor daily urine output volume
  • B. Drink plenty of water whenever thirsty
  • C. Use salt tablets for sodium content
  • D. Review food labels for sodium content
Correct Answer: D

Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.

The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?

  • A. Limit sodium intake to 2,300 mg per day
  • B. Engage in moderate exercise for 30 minutes daily
  • C. Consume a diet high in saturated fats
  • D. Avoid alcohol consumption completely
Correct Answer: B

Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

  • A. Decrease intake of fluids after the evening meal.
  • B. Drink a glass of cranberry juice every day.
  • C. Drink a glass of warm decaffeinated beverage at bedtime.
  • D. Consult the healthcare provider about a sleeping pill.
Correct Answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.

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