lOMoARcPSD|729 392 2
ALL.HESI.Fundamentals.Exam.Test.Bank.updated.2022/
2023
HESI.Fundamentals.Exam,.Answered
An.elderly.client.with.a.fractured.left.hip.is.on.strict.bedrest..Which.nursing.measure.is.e
ssential.to.the.client's.nursing.care?
A. Massage.any.reddened.areas.for.at.least.five.minutes.
B. Encourage.active.range.of.motion.exercises.on.extremities.
C. Position.the.client.laterally,.prone,.and.dorsally.in.sequence.
D. Gently.lift.the.client.when.moving.into.a.desired.position..-
.To.avoid.shearing.forces.when.repositioning,.the.client.should.be.lifted.gently.across.a.
surface.(D)..Reddened.areas.should.not.be.massaged.(A).since.this.may.increase.the.da
mage.to.already.traumatized.skin..To.control.pain.and.muscle.spasms,.active.range.of.
motion.(B).may.be.limited.on.the.affected.leg..The.position.described.in.(C).is.contrain
dicated.for.a.client.with.a.fractured.left.hip.
Correct.Answer:.D
The.nurse.is.administering.medications.through.a.nasogastric.tube.(NGT).which.is.
connected.to.suction..After.ensuring.correct.tube.placement,.what.action.should.the.
nurse.take.next?
A. Clamp.the.tube.for.20.minutes.
B. Flush.the.tube.with.water.
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C. Administer.the.medications.as.prescribed.
D. Crush.the.tablets.and.dissolve.in.sterile.water..-
.The.NGT.should.be.flushed.before,.after.and.in.between.each.medication.administere
d.(B)..Once.all.medications.are.administered,.the.NGT.should.be.clamped.for.20.minu
tes.(A)..(C.and.D).may.be.implemented.only.after.the.tubing.has.been.flushed.
Correct.Answer:.B
A.client.who.is.in.hospice.care.complains.of.increasing.amounts.of.pain..The.healthcare.p
rovider.prescribes.an.analgesic.every.four.hours.as.needed..Which.action.should.the.nurs
e.implement?
A. Give.an.around-the-clock.schedule.for.administration.of.analgesics.
B. Administer.analgesic.medication.as.needed.when.the.pain.is.severe.
C. Provide.medication.to.keep.the.client.sedated.and.unaware.of.stimuli.
D. Offer.a.medication-free.period.so.that.the.client.can.do.daily.activities..-
.The.most.effective.management.of.pain.is.achieved.using.an.around-the-
clock.schedule.that.provides.analgesic.medications.on.a.regular.basis.(A).and.in.a.timel
y.manner..Analgesics.are.less.effective.if.pain.persists.until.it.is.severe,.so.an.analgesic.
medication.should.be.administered.before.the.client's.pain.peaks.(B)..Providing.comfort
.is.a.priority.for.the.client.who.is.dying,.but.sedation.that.impairs.the.client's.ability.to.i
nteract.and.experience.the.time.before.life.ends.should.be.minimized.(C)..Offering.a.m
edication-
free.period.allows.the.serum.drug.level.to.fall,.which.is.not.an.effective.method.to.man
age.chronic.pain.(D).
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, lOMoARcPSD|729 392 2
Correct.Answer:.A
When.assessing.a.client.with.wrist.restraints,.the.nurse.observes.that.the.fingers.on.the.rig
ht.hand.are.blue..What.action.should.the.nurse.implement.first?
A. Loosen.the.right.wrist.restraint.
B. Apply.a.pulse.oximeter.to.the.right.hand.
C. Compare.hand.color.bilaterally.
D. Palpate.the.right.radial.pulse..-
.The.priority.nursing.action.is.to.restore.circulation.by.loosening.the.restraint.(A),.becau
se.blue.fingers.(cyanosis).indicates.decreased.circulation..(C.and.D).are.also.important.
nursing.interventions,.but.do.not.have.the.priority.of.(A)..Pulse.oximetry.(B).measures.
the.saturation.of.hemoglobin.with.oxygen.and.is.not.indicated.in.situations.where.the.c
yanosis.is.related.to.mechanical.compression.(the.restraints).
Correct.Answer:.A
The.nurse.is.assessing.the.nutritional.status.of.several.clients..Which.client.has.the.greates
t.nutritional.need.for.additional.intake.of.protein?
A. A.college-age.track.runner.with.a.sprained.ankle.
B. A.lactating.woman.nursing.her.3-day-old.infant.
C. A.school-aged.child.with.Type.2.diabetes.
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D. An.elderly.man.being.treated.for.a.peptic.ulcer..-
.A.lactating.woman.(B).has.the.greatest.need.for.additional.protein.intake..(A,.C,.and.
D).are.all.conditions.that.require.protein,.but.do.not.have.the.increased.metabolic.prote
in.demands.of.lactation.
Correct.Answer:.B
A.client.is.in.the.radiology.department.at.0900.when.the.prescription.levofloxacin.(Lev
aquin).500.mg.IV.q24h.is.scheduled.to.be.administered..The.client.returns.to.the.unit.at.
1300..What.is.the.best.intervention.for.the.nurse.to.implement?
A. Contact.the.healthcare.provider.and.complete.a.medication.variance.form.
B. Administer.the.Levaquin.at.1300.and.resume.the.0900.schedule.in.the.morning.
C. Notify.the.charge.nurse.and.complete.an.incident.report.to.explain.the.missed.dose.
D. Give.the.missed.dose.at.1300.and.change.the.schedule.to.administer.daily.at.1300..-
.To.ensure.that.a.therapeutic.level.of.medication.is.maintained,.the.nurse.should.admini
ster.the.missed.dose.as.soon.as.possible,.and.revise.the.administration.schedule.accordi
ngly.to.prevent.dangerously.increasing.the.level.of.the.medication.in.the.bloodstream.(
D)..The.nurse.should.document.the.reason.for.the.late.dose,.but.(A.and.C).are.not.warra
nted..(B).could.result.in.increased.blood.levels.of.the.drug.
Correct.Answer:.D
While.instructing.a.male.client's.wife.in.the.performance.of.passive.range-of-
motion.exercises.to.his.contracted.shoulder,.the.nurse.observes.that.she.is.holding.hi
s.arm.above.and.below.the.elbow..What.nursing.action.should.the.nurse.implement?
Downloaded by jane murage ()
ALL.HESI.Fundamentals.Exam.Test.Bank.updated.2022/
2023
HESI.Fundamentals.Exam,.Answered
An.elderly.client.with.a.fractured.left.hip.is.on.strict.bedrest..Which.nursing.measure.is.e
ssential.to.the.client's.nursing.care?
A. Massage.any.reddened.areas.for.at.least.five.minutes.
B. Encourage.active.range.of.motion.exercises.on.extremities.
C. Position.the.client.laterally,.prone,.and.dorsally.in.sequence.
D. Gently.lift.the.client.when.moving.into.a.desired.position..-
.To.avoid.shearing.forces.when.repositioning,.the.client.should.be.lifted.gently.across.a.
surface.(D)..Reddened.areas.should.not.be.massaged.(A).since.this.may.increase.the.da
mage.to.already.traumatized.skin..To.control.pain.and.muscle.spasms,.active.range.of.
motion.(B).may.be.limited.on.the.affected.leg..The.position.described.in.(C).is.contrain
dicated.for.a.client.with.a.fractured.left.hip.
Correct.Answer:.D
The.nurse.is.administering.medications.through.a.nasogastric.tube.(NGT).which.is.
connected.to.suction..After.ensuring.correct.tube.placement,.what.action.should.the.
nurse.take.next?
A. Clamp.the.tube.for.20.minutes.
B. Flush.the.tube.with.water.
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, lOMoARcPSD|729 392 2
C. Administer.the.medications.as.prescribed.
D. Crush.the.tablets.and.dissolve.in.sterile.water..-
.The.NGT.should.be.flushed.before,.after.and.in.between.each.medication.administere
d.(B)..Once.all.medications.are.administered,.the.NGT.should.be.clamped.for.20.minu
tes.(A)..(C.and.D).may.be.implemented.only.after.the.tubing.has.been.flushed.
Correct.Answer:.B
A.client.who.is.in.hospice.care.complains.of.increasing.amounts.of.pain..The.healthcare.p
rovider.prescribes.an.analgesic.every.four.hours.as.needed..Which.action.should.the.nurs
e.implement?
A. Give.an.around-the-clock.schedule.for.administration.of.analgesics.
B. Administer.analgesic.medication.as.needed.when.the.pain.is.severe.
C. Provide.medication.to.keep.the.client.sedated.and.unaware.of.stimuli.
D. Offer.a.medication-free.period.so.that.the.client.can.do.daily.activities..-
.The.most.effective.management.of.pain.is.achieved.using.an.around-the-
clock.schedule.that.provides.analgesic.medications.on.a.regular.basis.(A).and.in.a.timel
y.manner..Analgesics.are.less.effective.if.pain.persists.until.it.is.severe,.so.an.analgesic.
medication.should.be.administered.before.the.client's.pain.peaks.(B)..Providing.comfort
.is.a.priority.for.the.client.who.is.dying,.but.sedation.that.impairs.the.client's.ability.to.i
nteract.and.experience.the.time.before.life.ends.should.be.minimized.(C)..Offering.a.m
edication-
free.period.allows.the.serum.drug.level.to.fall,.which.is.not.an.effective.method.to.man
age.chronic.pain.(D).
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Correct.Answer:.A
When.assessing.a.client.with.wrist.restraints,.the.nurse.observes.that.the.fingers.on.the.rig
ht.hand.are.blue..What.action.should.the.nurse.implement.first?
A. Loosen.the.right.wrist.restraint.
B. Apply.a.pulse.oximeter.to.the.right.hand.
C. Compare.hand.color.bilaterally.
D. Palpate.the.right.radial.pulse..-
.The.priority.nursing.action.is.to.restore.circulation.by.loosening.the.restraint.(A),.becau
se.blue.fingers.(cyanosis).indicates.decreased.circulation..(C.and.D).are.also.important.
nursing.interventions,.but.do.not.have.the.priority.of.(A)..Pulse.oximetry.(B).measures.
the.saturation.of.hemoglobin.with.oxygen.and.is.not.indicated.in.situations.where.the.c
yanosis.is.related.to.mechanical.compression.(the.restraints).
Correct.Answer:.A
The.nurse.is.assessing.the.nutritional.status.of.several.clients..Which.client.has.the.greates
t.nutritional.need.for.additional.intake.of.protein?
A. A.college-age.track.runner.with.a.sprained.ankle.
B. A.lactating.woman.nursing.her.3-day-old.infant.
C. A.school-aged.child.with.Type.2.diabetes.
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D. An.elderly.man.being.treated.for.a.peptic.ulcer..-
.A.lactating.woman.(B).has.the.greatest.need.for.additional.protein.intake..(A,.C,.and.
D).are.all.conditions.that.require.protein,.but.do.not.have.the.increased.metabolic.prote
in.demands.of.lactation.
Correct.Answer:.B
A.client.is.in.the.radiology.department.at.0900.when.the.prescription.levofloxacin.(Lev
aquin).500.mg.IV.q24h.is.scheduled.to.be.administered..The.client.returns.to.the.unit.at.
1300..What.is.the.best.intervention.for.the.nurse.to.implement?
A. Contact.the.healthcare.provider.and.complete.a.medication.variance.form.
B. Administer.the.Levaquin.at.1300.and.resume.the.0900.schedule.in.the.morning.
C. Notify.the.charge.nurse.and.complete.an.incident.report.to.explain.the.missed.dose.
D. Give.the.missed.dose.at.1300.and.change.the.schedule.to.administer.daily.at.1300..-
.To.ensure.that.a.therapeutic.level.of.medication.is.maintained,.the.nurse.should.admini
ster.the.missed.dose.as.soon.as.possible,.and.revise.the.administration.schedule.accordi
ngly.to.prevent.dangerously.increasing.the.level.of.the.medication.in.the.bloodstream.(
D)..The.nurse.should.document.the.reason.for.the.late.dose,.but.(A.and.C).are.not.warra
nted..(B).could.result.in.increased.blood.levels.of.the.drug.
Correct.Answer:.D
While.instructing.a.male.client's.wife.in.the.performance.of.passive.range-of-
motion.exercises.to.his.contracted.shoulder,.the.nurse.observes.that.she.is.holding.hi
s.arm.above.and.below.the.elbow..What.nursing.action.should.the.nurse.implement?
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