HESI Fundamentals Test Bank

Correct Answer: C

Rationale: The correct answer is C. Taking water pills (diuretics) only when feeling short of breath is incorrect. Diuretics should be taken regularly as prescribed to help manage fluid retention in chronic heart failure. This statement indicates a need for further teaching as the client needs to understand the importance of consistent medication adherence. Choices A, B, and D demonstrate good understanding of self-care management in heart failure, including daily weight monitoring, prompt reporting of worsening symptoms to the healthcare provider, and dietary sodium restriction, respectively.

Correct Answer: B

Rationale: The correct action for the nurse to include when assessing the client's gag reflex is to place a tongue blade on the back half of the tongue. This method effectively tests the gag reflex without causing discomfort. Choice A is incorrect because offering small sips of water through a straw does not assess the gag reflex. Choice C is incorrect as using a penlight to observe the back of the oral cavity does not directly assess the gag reflex. Choice D is incorrect since auscultating breath sounds after the client swallows does not evaluate the gag reflex.

Correct Answer: C

Rationale: Checking for jugular vein distention is crucial in assessing fluid overload in clients with heart failure. Jugular vein distention indicates increased central venous pressure, which can be a sign of worsening heart failure. Monitoring oxygen saturation (Choice A) is important but may not provide immediate information on fluid status. Assessing the apical pulse (Choice B) is relevant for monitoring heart rate but may not directly indicate fluid overload. Measuring urine output (Choice D) is essential for assessing renal function and fluid balance but does not provide immediate information on fluid overload in this scenario.

Correct Answer: A

Rationale: The correct answer is A. A 16-year-old who is married can legally sign an informed consent form. In this case, being married at 16 may indicate legal emancipation or the ability to consent to medical treatment. Choice B is incorrect because having schizophrenia doesn't automatically imply incapacity to provide informed consent. Choice C is incorrect as an adoptive parent does not have the legal authority to provide consent for medical treatment on behalf of a child without proper documentation. Choice D is incorrect as a 17-year-old mother would generally not have the legal capacity to give consent for her toddler, as parental consent is usually required for minors.

Correct Answer: A

Rationale: When developing an individualized plan of care for a patient, the nurse must set goals that are specific, measurable, achievable, realistic, and time-bound (SMART). Choice A is correct as it emphasizes the importance of establishing goals that are measurable and realistic, ensuring they are attainable within a specific timeframe. Setting goals that are beyond the capabilities of the patient (Choice B) can lead to frustration and lack of progress. Using only the nurse's judgment and disregarding family desires (Choice C) may not consider important aspects of the patient's social support and preferences. Explaining that progress requires taking alignment risks (Choice D) is not a standard approach in nursing care planning and may confuse the patient or hinder trust in the nurse's decision-making.