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Free hesi foundation of nursing Questions

1.

A client diagnosed with primary open angle glaucoma received a prescription for miotic eye drops. Which instruction should the nurse plan to include in this client's teaching?

  • "Administer the medication directly on the cornea."

  • "Squeeze your eye closed after administering the drops."

  • "Wash your hands after each administration of eye drops."

  • "Do not allow the dropper bottle to touch the eye."

Explanation

Explanation
Correct Answer: D) "Do not allow the dropper bottle to touch the eye."
A critical instruction for any eye drop administration is that the dropper tip must never touch the eye, eyelid, or any surface. Contact with the eye contaminates the dropper tip, which can introduce bacteria into the bottle and lead to serious ocular infections. This is the most important safety teaching point for eye drop administration.
Option A is incorrect — eye drops should be instilled into the conjunctival sac (lower eyelid), not directly onto the cornea, as this can cause irritation and discomfort. Option B is incorrect — the client should gently close the eye and apply light pressure to the inner corner (nasolacrimal duct) to prevent systemic absorption, not squeeze the eye tightly.
Option C is correct practice but washing hands before administration is more critical than after, and this is not the priority teaching point specific to miotic drops.
2.

Which action should the nurse implement when inserting an indwelling catheter for an uncircumcised male client?

  • Advance the catheter before inflating balloon

  • Position the sterile field even with the nurse's hips

  • Clean the urinary meatus before retracting the foreskin

  • Use a swab to wipe the meatus in back-and-forth motions

Explanation

Explanation
Correct Answer: A) Advance the catheter until urine flows and then advance 1-2 inches more before inflating the balloon
When inserting an indwelling urinary catheter, the balloon must never be inflated until urine return is confirmed and the catheter has been advanced an additional 1–2 inches to ensure the balloon is fully inside the bladder and not in the urethra. Inflating the balloon in the urethra causes severe pain and urethral injury.
For an uncircumcised male, the foreskin must be retracted before cleaning — not after — to properly expose and clean the urinary meatus. Cleaning should be performed in a circular motion from the meatus outward, not back-and-forth which would introduce bacteria. The sterile field should be positioned at thigh level, not at the nurse's hips, to maintain sterility and proper technique.
3.

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

  • Release the manometer valve immediately

  • Inflate blood pressure cuff to 120 mm Hg

  • Document the absence of the radial pulse

  • Record a palpable systolic pressure of 90 mm Hg

Explanation

Explanation
Correct Answer: B) Inflate blood pressure cuff to 120 mm Hg
When obtaining a systolic blood pressure by palpation, the nurse inflates the cuff until the radial pulse is no longer palpable — this point estimates the systolic pressure. However, the cuff should be inflated an additional 30 mm Hg beyond the point where the pulse disappears to ensure an accurate reading and avoid underestimating the systolic pressure.
Since the pulse disappeared at 90 mm Hg, the cuff should be inflated to 120 mm Hg (90 + 30). Releasing the valve immediately would give an inaccurate reading. Documenting the absence of the radial pulse is incorrect — this is an expected and normal part of the palpation technique. Recording 90 mm Hg as the systolic pressure at this point would be premature and inaccurate.
4.

The nurse educator is conducting a class for unlicensed assistive personnel (UAP). Which action indicates that a UAP understands gloving procedures?

  • Uses sterile gloves when handling body fluids

  • Keeps a pair of gloves in uniform pocket

  • Dons sterile gloves when caring for clients with HIV

  • Puts on new gloves when entering a client's room

Explanation

Explanation
Correct Answer: A) Uses sterile gloves when handling body fluids

Standard infection control practice requires the use of gloves when handling body fluids to protect both the healthcare worker and the client from transmission of infectious organisms. Using gloves when handling body fluids demonstrates correct understanding of gloving procedures and standard precautions.

Keeping gloves in a uniform pocket is incorrect — gloves stored in pockets become contaminated and are not appropriate for use. Sterile gloves are not required for routine care of clients with HIV — clean gloves are sufficient for standard precautions, as HIV is not transmitted through casual contact.

Putting on new gloves simply when entering a client's room without a specific indication is not a recommended practice and wastes resources.
5.

A 36-year-old female presents to the clinic reporting difficulty sleeping that began 2 years ago following her father's death. She has no medical problems, takes an oral contraceptive and a multivitamin daily, does not smoke, and drinks 1 to 2 glasses of wine every evening. Which recommendations could the nurse give to help the client achieve better sleep? Select all that apply.

  • Avoid alcohol in the evening

  • Take an analgesic before bed

  • Watch television in bed to fall asleep

  • Try to go to bed and awaken at the same time every day

  • Avoid naps

  • Eat a heavy meal before bed

  • Exercise in the evening

Explanation

Explanation
Correct Answers: A) Avoid alcohol in the evening, D) Try to go to bed and awaken at the same time every day, and E) Avoid naps
This client's insomnia likely has both a psychological trigger (grief following her father's death) and a behavioral contributor (nightly alcohol use). Although alcohol may initially induce drowsiness, it disrupts sleep architecture and reduces sleep quality — making avoiding alcohol in the evening a key recommendation.
Maintaining a consistent sleep and wake schedule reinforces the body's circadian rhythm and is one of the most evidence-based interventions for insomnia. Avoiding daytime naps helps build sleep pressure at night, making it easier to fall and stay asleep. Taking an analgesic is not indicated as the client has no pain complaints.
Watching television in bed is counterproductive as it associates the bed with wakefulness rather than sleep — a violation of good sleep hygiene. Eating a heavy meal before bed can cause discomfort and disrupt sleep. Exercising in the evening can be stimulating and may delay sleep onset for some individuals, making earlier in the day the preferred time for exercise.
6.

A client on a mechanical soft diet is experiencing constipation and asks the nurse for a glass of prune juice. After auscultating decreased bowel sounds, which action should the nurse implement?

  • Advance to a regular diet

  • Offer to warm the prune juice

  • Initiate bowel training protocol

  • Restrict oral fluid intake

Explanation

Explanation
Correct Answer: B) Offer to warm the prune juice
Prune juice is a natural laxative that contains sorbitol and fiber, making it an appropriate and non-invasive first intervention for constipation. Warming the prune juice can further stimulate peristalsis and bowel motility, which is especially helpful given the finding of decreased bowel sounds. This is a safe, appropriate nursing action that addresses the client's request and supports bowel function without overstepping dietary orders.
Advancing to a regular diet requires a physician's order and is not within the nurse's independent scope. Initiating a bowel training protocol is a more involved intervention not warranted as the first step. Restricting oral fluid intake would worsen constipation, as adequate hydration is essential for normal bowel function.
7.

The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?

  • Demonstrate proper securing of the restraints

  • Complete an adverse occurrence/incident report

  • Initiate the facility's restraint flow sheet

  • Ensure that the restraints are not too tight

Explanation

Explanation
Correct Answer: A) Demonstrate proper securing of the restraints
Securing restraints to the bedside rails is a safety violation and incorrect technique. If the bed rails are raised or lowered, restraints attached to them can cause serious injury, strangulation, or death by pulling the client's limbs into dangerous positions. Restraints must always be secured to the moveable part of the bed frame, not the side rails.
The most important and immediate nursing action is to intervene and demonstrate the correct technique to the UAP to prevent imminent patient harm. Completing an incident report and initiating the restraint flow sheet are important documentation steps but are not the priority when the client is at immediate risk. Checking that restraints are not too tight is also important but is secondary to first correcting the dangerous placement.
8.

A 75-year-old male presents to the emergency department with poorly controlled diabetes. He has been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. He was stabilized in the ED and transferred to the medical unit. He has a history of moderate obesity, insulin dependent diabetes, smoking one pack per day for 40 years, and mobility issues requiring a walker. The nurse reviews the client's data. Which potential condition, actions to take, and parameters to monitor are most appropriate for this client? Select all that apply.


Actions to Take:


Potential Condition:


Parameters to Monitor:

  • Administer an enema

  • Contact adult protective services

  • Offload coccyx and other bony prominences

  • Cleanse and dress wound

  • Immediately begin a bowel training program

  • Bowel obstruction

  • Altered nutrition

  • Pressure injury

  • Elder abuse

  • Documentation of skin prevention measures

  • Wound status

  • Incontinence episodes

  • Family dynamics

  • Vital signs

Explanation

Explanation Correct Answers: Actions to Take: C) Offload coccyx and other bony prominences and D) Cleanse and dress wound | Potential Condition: C) Pressure injury | Parameters to Monitor: A) Documentation of skin prevention measures and B) Wound status

This client is at high risk for a pressure injury due to multiple compounding risk factors including advanced age (75 years), obesity, immobility requiring a walker, poorly controlled diabetes which impairs circulation and wound healing, and a long history of smoking which reduces tissue oxygenation.

The priority potential condition is a pressure injury. The appropriate nursing actions are to offload the coccyx and other bony prominences to relieve pressure and prevent further tissue damage, and to cleanse and dress any existing wound to promote healing and prevent infection.

The most relevant parameters to monitor are documentation of skin prevention measures to ensure consistent preventive care is being implemented, and wound status to track healing progress or detect deterioration.

Elder abuse and bowel obstruction are not supported by the clinical data provided. Vital signs, while always important, are not the most specific parameters for monitoring pressure injury progress in this scenario.
9.

A client with atrial fibrillation receives a prescription for a loading dose of digoxin 0.5 mg PO. The medication is available in 125 mcg tablets. How many tablets should the nurse administer? (Enter numerical value only.)

Explanation

Explanation
Correct Answer: 4 tablets
First, convert units to ensure consistency: 0.5 mg = 500 mcg. Then apply the dose calculation formula: Desired dose ÷ Available dose = Number of tablets. 500 mcg ÷ 125 mcg per tablet = 4 tablets. The nurse should administer 4 tablets to deliver the prescribed 0.5 mg loading dose of digoxin.
10.

A 75-year-old male presents to the emergency department with poorly controlled diabetes. He has been experiencing polyuria, nausea and vomiting, confusion, and unstable blood sugars. He was stabilized in the ED and transferred to the medical unit. He has a history of moderate obesity, insulin dependent diabetes, smoking one pack per day for 40 years, and mobility issues requiring a walker. The nurse reviews the client's data. Which potential condition, actions to take, and parameters to monitor are most appropriate for this client? Select all that apply.

  • Administer an enema

  • Contact adult protective services

  • Offload coccyx and other bony prominences

  • Cleanse and dress wound

  • Immediately begin a bowel training program

  • Bowel obstruction

  • Altered nutrition

  • Pressure injury

  • Elder abuse

  • Documentation of skin prevention measures

  • Wound status

  • Incontinence episodes

  • Family dynamics

  • Vital signs

Explanation

Explanation
Correct Answers: Actions to Take: C) Offload coccyx and other bony prominences and D) Cleanse and dress wound | Potential Condition: C) Pressure injury | Parameters to Monitor: A) Documentation of skin prevention measures and B) Wound status
This client is at high risk for a pressure injury due to multiple compounding risk factors including advanced age (75 years), obesity, immobility requiring a walker, poorly controlled diabetes which impairs circulation and wound healing, and a long history of smoking which reduces tissue oxygenation.

The priority potential condition is a pressure injury. The appropriate nursing actions are to offload the coccyx and other bony prominences to relieve pressure and prevent further tissue damage, and to cleanse and dress any existing wound to promote healing and prevent infection.

The most relevant parameters to monitor are documentation of skin prevention measures to ensure consistent preventive care is being implemented, and wound status to track healing progress or detect deterioration.

Elder abuse and bowel obstruction are not supported by the clinical data provided. Vital signs, while always important, are not the most specific parameters for monitoring pressure injury progress in this scenario.

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