HESI EXIT EXAM FUNDAMENTAL – QUESTION AND ANSWERS WITH RATIONALE

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? Which nursing interventions require a nurse to wear gloves? (Select ...

A nurse is teaching staff members about the legal terminology used in child abuse. What definition of battery should the nurse include in the teaching? Which nursing interventions require a nurse to wear gloves? (Select all that apply.) A nurse is caring for a client with hemiplegia who is frustrated. How can the nurse motivate the client toward independence? A health care provider prescribes a standard walker (pick-up walker with rubber tips on all four legs). The nurse identifies what clinical findings that indicate the client is capable of using a standard walker? To prevent footdrop in a client with a leg cast, the nurse should: What should the nurse include in dietary teaching for a client with a colostomy? A client with respiratory difficulties asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to: 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 neurological impairment. Legally, who is responsible for the child’s injury? On the third postoperative day following a below-the-knee amputation, a client is refusing to eat, talk, or perform any rehabilitative activities. What is the best initial approach that the nurse should take when interacting with this client? While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as: The nurse is teaching a client about adequate hand hygiene. What component of hand washing should the nurse include that is most important for removing microorganisms? A nurse identifies that an older adult has not achieved the desired outcome from a prescribed proprietary medication. When assessing the situation, the client shares that the medication is too expensive and the prescription was never filled. What is an appropriate nursing response? A client with heart failure is on a drug regimen of digoxin (Lanoxin) and furosemide (Lasix). The client dislikes oranges and bananas. Which fruit should the nurse encourage the client to eat? What is the best nursing intervention to minimize perineal edema after an episiotomy? A client is admitted to the hospital after a motor vehicle accident with multiple abrasions and lacerations to the chest and all four extremities. The nurse helps the client select food items for the upcoming meals and recommends: A client newly diagnosed with myasthenia gravis is concerned about fluctuations in physical condition and generalized weakness. When caring for this client it is most important for the nurse to plan to: An older client’s colonoscopy reveals the presence of extensive diverticulosis. What type of diet should the nurse encourage the client to follow? A client with a left ureteral calculus is scheduled for a transurethral ureterolithotomy. During the preoperative assessment, the nurse expects the client to report pain: A client is cautioned to avoid vitamin D toxicity while increasing protein intake. Which nutrient selected by the client indicates to the nurse that the dietary teaching is understood? The nurse teaches a client who developed degenerative joint disease of the vertebral column positioning techniques, including turning from back to side, keeping the spine straight. The nurse explains that the least effort will be exerted if the client crosses the arm over the chest and: A client was recently diagnosed with a cancerous lesion of the mouth. What should the nurse ask when analyzing the client’s need for health education in relation to this health problem? A nurse is teaching a class about hepatitis, specifically hepatitis A. Which food should the nurse explain most likely will remain contaminated with the hepatitis A virus after being cooked? A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterize the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as: A mother whose newborn infant son has a cleft lip and palate asks how to feed her baby because he has difficulty suckling. What information should the nurse provide concerning safe feeding technique for this infant? A client who has been in a coma for two months is being maintained on bed rest. The nurse concludes that to prevent the effects of shearing force, the head of the bed should be maintained at an angle of: A client is receiving a 2-gram sodium diet. The family asks whether they can bring snacks from home. The nurse suggests that they bring foods low in sodium such as: A client is hospitalized for the treatment of thrombophlebitis. What should the nurse include in the client’s teaching plan related to how to prevent thrombophlebitis? Discharge planning for an ambulatory client with Parkinson disease (PD) includes recommending equipment for home use that will help with activities of daily living. To foster independence, the nurse should promote the use of: A client’s serum albumin value is 2.8 g/dL. Which food selected by the client indicates that the nurse’s dietary teaching is successful? A nurse in a rehabilitation center teaches clients with quadriplegia to use an adaptive wheelchair. Why is it important that the nurse provide this instruction? Why is it important for a nurse in the prenatal clinic to provide nutritional counseling to all newly pregnant women? A nurse is providing dietary teaching for a client with celiac disease. Which foods should the nurse teach the client to avoid when following a gluten-free diet? (Select all that apply.) A client is experiencing stomatitis as a result of chemotherapy. Which nursing action is most appropriate when caring for this client? A nurse is monitoring a client with renal failure for signs of fluid excess. Which finding does the nurse identify as inconsistent with fluid excess? When assisting a client who had a total hip replacement onto the bedpan on the first postoperative day, the nurse should instruct the client to: Which alternative therapy may be beneficial for the nurse to discuss with a client who has terminal bone cancer? A nurse reviews the prescribed treatment with the parents of an infant born with bilateral clubfeet. Which parental statement indicates to the nurse that further education is required? fter surgery for a fractured hip, a client states, “I don’t remember when I have ever been so uncomfortable.” The nurse should: A client with pulmonary tuberculosis discusses the dietary plan with the nurse. The nurse expects that the type of diet that will be prescribed for the client is: A nurse is evaluating a client’s response to fluid replacement therapy. Which clinical finding indicates adequate tissue perfusion to vital organs? A preschooler is admitted with a diagnosis of acute glomerulonephritis. The child’s history reveals a 5-lb weight gain in 1 week and periorbital edema. How can the nurse obtain the most accurate information on the status of the child’s edema? A 75-year-old female client tells the nurse that she read about a vitamin that may be related to aging because of its relationship to the structure of cell walls. The nurse determines that the client is probably referring to: A nurse is teaching a postoperative client about the importance of vitamin C for wound healing. Which food selection demonstrates the client is applying the information correctly?