HESI Fundamentals 2023 Test Bank

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A nurse is caring for a client who is postoperative and has signs of hemorrhagic shock. When the nurse notifies the surgeon, he directs her to continue to measure the client's vitals every 15 minutes and call him back in 1 hour. From a legal perspective, which of the following actions should the nurse take next?

  • A. Notify the nursing manager.
  • B. Document the client's condition and communication with the surgeon.
  • C. Administer additional fluids as per standard procedure.
  • D. Call the surgeon back immediately to ensure timely intervention.
Correct Answer: B

Rationale: In this scenario, the nurse should choose option B, which is to document the client's condition and communication with the surgeon. By documenting the client's condition and the communication with the surgeon, the nurse ensures legal protection and maintains continuity of care. This documentation serves as evidence of the actions taken, communication exchanged, and the rationale behind decisions made. Option A, notifying the nursing manager, may not be necessary at this stage unless there are specific institutional protocols requiring it. Administering additional fluids without further clarification may not be appropriate and could worsen the client's condition if not indicated. Calling the surgeon back immediately (option D) may disrupt the agreed-upon plan of action and fail to follow the surgeon's instructions of reassessment after an hour.

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The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the nurse implement first?

  • A. Check the drainage tubing for a kink
  • B. Review the intake and output record
  • C. Notify the healthcare provider
  • D. Give the client 8 oz of water to drink
Correct Answer: A

Rationale: The correct answer is to check the drainage tubing for a kink. A kink in the tubing can obstruct urine flow, potentially causing the low output. By addressing this first, the nurse can ensure that there are no physical obstructions hindering urine drainage. Reviewing the intake and output record is important, but addressing a possible kink in the tubing takes precedence as it directly affects urine flow. Notifying the healthcare provider should be considered after assessing and resolving immediate issues. Giving the client water to drink may be appropriate, but addressing a kink in the tubing is the priority to ensure proper function of the urinary catheter.

A client with a history of heart failure is admitted with weight gain and peripheral edema. Which medication should the LPN/LVN anticipate being prescribed?

  • A. Lisinopril (Zestril)
  • B. Furosemide (Lasix)
  • C. Metoprolol (Lopressor)
  • D. Simvastatin (Zocor)
Correct Answer: B

Rationale: Furosemide (Lasix) is the correct answer. In a client with heart failure experiencing weight gain and peripheral edema, the priority is to manage fluid overload. Furosemide is a loop diuretic commonly prescribed to reduce excess fluid in heart failure patients. Lisinopril (Zestril) is an ACE inhibitor used to treat hypertension and heart failure but does not directly address fluid overload. Metoprolol (Lopressor) is a beta-blocker that helps manage heart failure symptoms but does not primarily target fluid retention. Simvastatin (Zocor) is a statin used to lower cholesterol levels and is not indicated for managing fluid overload in heart failure.

A client with heart failure is being taught by a nurse on reducing daily sodium intake. Which factor is most crucial in determining the client's ability to learn new dietary habits?

  • A. The client's involvement in planning the change
  • B. The cost of the dietary changes
  • C. The availability of low-sodium foods
  • D. The client's previous dietary knowledge
Correct Answer: D

Rationale: The client's previous dietary knowledge is the most critical factor in determining the ability to learn new dietary habits. Understanding the client's existing dietary knowledge helps tailor the teaching to build upon what they already know. While client involvement in planning changes can increase adherence and motivation, the foundational knowledge is essential for effective learning. The cost of dietary changes and the availability of low-sodium foods are important considerations but not as crucial as the client's existing knowledge.

A nurse is teaching the parents of a toddler about discipline. Which of the following actions should the nurse suggest?

  • A. Establish consistent boundaries for the toddler.
  • B. Place the toddler in a room with the door closed.
  • C. Inform the toddler how you feel when he misbehaves.
  • D. Use a favorite snack to reward the toddler.
Correct Answer: A

Rationale: The correct answer is to establish consistent boundaries for the toddler. This approach helps toddlers understand expectations and promotes consistent behavior. Placing the toddler alone or using food rewards may not effectively teach discipline and could be inappropriate. Informing the toddler about feelings when misbehaving may not be developmentally appropriate for a toddler to understand the consequences of their actions.

A client who had a cerebrovascular accident has persistent problems with dysphagia. The nurse caring for the client should initiate a referral with which of the following members of the interprofessional care team?

  • A. Social worker
  • B. Certified nursing assistant
  • C. Occupational therapist
  • D. Speech-language pathologist
Correct Answer: D

Rationale: The correct answer is D, Speech-language pathologist. Speech-language pathologists specialize in assessing and treating dysphagia, which is a common issue following a cerebrovascular accident. They are trained to evaluate swallowing function and provide appropriate interventions to help clients improve their ability to swallow safely. Choice A, Social worker, is incorrect as their role does not typically involve addressing dysphagia specifically. Choice B, Certified nursing assistant, is not the appropriate professional to address dysphagia concerns as they do not have the training or scope of practice for this specialized area. Choice C, Occupational therapist, focuses more on activities of daily living and functional abilities rather than the specialized treatment of dysphagia.

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