HESI FUNDAMENTALS PRACTICE EXAM
The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. - ANSWER-Observe the
appearance of the skin under the ice pack (The first action taken by the nurse
should be to assess the skin for any possible thermal injury. If no injury to the skin
has occurred, the nurse can take the other actions.)
The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor
of 60 gtt/mL, how many drops per minute should the client receive? - ANSWER-
124 gtt/min
The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/
30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10
pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml
administration set. The nurse plans to set the flow rate at how many gtt/min? -
ANSWER-83 gtt/min
Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube? - ANSWER-Examining a chest x-ray obtained
after the tubing was inserted
,Three days following a surgery, a male client observes his colostomy for the first
time. He becomes quite upset and tells the nurse that it is much bigger than he
expected. What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance
in time.
B. Instruct the client that the stoma will become much smaller when the initial
swelling diminishes.
C. Offer to contact a member of the local ostomy support group to help him with
his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with
the procedure. - ANSWER-B. Instruct the client that the stoma will become smaller
when the initial swelling diminishes (Postoperative swelling causes enlargement of
the stoma. The nurse can teach the client that the stoma will become smaller
when swelling is diminished (B). This will help reduce the client's anxiety and
promote acceptance of the colostomy. (A) does not provide helpful teaching or
support. (C) is a useful action, and may be taken after the nurse provides pertinent
teaching. The client is not yet demonstrating readiness to learn colostomy care.
(D)
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - ANSWER-B.
Reposition the client on her side. (The immediate priority is to determine if the
,tube is functioning correctly, which would then relieve the client's nausea. The
least invasive intervention (B) should be attempted first, followed by (A and C),
unless either of these interventions is contraindicated. If these measures are
unsuccessful, the client may require an antiemetic (D))
A hospitalized male client is receiving nasogastric tube feedings via a small-bore
tube and a continuous pump infusion. He reports that he had a bad bout of severe
coughing a few minutes ago, but feels fine now. What action is best for the nurse
to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the
HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
- ANSWER-C. After clearing the tube with 30 ml of air, check the pH of fluid
withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - ANSWER-D. is disoriented to place and time
(The client is exhibiting disorientation (D). (A) refers to memory of the distant
past. The client is able to express himself without difficulty (B), and does not
demonstrate diminished attention span. (C).
, A client with chronic kidney disease (CKD) selects a scrambled egg for his
breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. -
ANSWER-A. Commend the client for selecting a high biologic value protein. (Foods
such as eggs and milk (A) are high biologic proteins which are allowed because
they are complete proteins and supply the essential amino acids that are
necessary for growth and cell repair. Orange juice is rich in potassium and should
not be encouraged. The client has made a good diet choice so (D) is not
necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to
realize that the center of gravity for an elderly person is the-- - ANSWER-Upper
torso (The center of gravity for adults is the hips. However, as the person grows
older, a stooped posture is common because of the changes from osteoporosis
and normal bone degeneration, and the knees, hips, and elbows flex. This stooped
posture results in the upper torso becoming the center of gravity for older
persons.)
In developing a plan of care for a client with dementia, the nurse should
remember that confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin. - ANSWER-Observe the
appearance of the skin under the ice pack (The first action taken by the nurse
should be to assess the skin for any possible thermal injury. If no injury to the skin
has occurred, the nurse can take the other actions.)
The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor
of 60 gtt/mL, how many drops per minute should the client receive? - ANSWER-
124 gtt/min
The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/
30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10
pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml
administration set. The nurse plans to set the flow rate at how many gtt/min? -
ANSWER-83 gtt/min
Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube? - ANSWER-Examining a chest x-ray obtained
after the tubing was inserted
,Three days following a surgery, a male client observes his colostomy for the first
time. He becomes quite upset and tells the nurse that it is much bigger than he
expected. What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appearance
in time.
B. Instruct the client that the stoma will become much smaller when the initial
swelling diminishes.
C. Offer to contact a member of the local ostomy support group to help him with
his concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with
the procedure. - ANSWER-B. Instruct the client that the stoma will become smaller
when the initial swelling diminishes (Postoperative swelling causes enlargement of
the stoma. The nurse can teach the client that the stoma will become smaller
when swelling is diminished (B). This will help reduce the client's anxiety and
promote acceptance of the colostomy. (A) does not provide helpful teaching or
support. (C) is a useful action, and may be taken after the nurse provides pertinent
teaching. The client is not yet demonstrating readiness to learn colostomy care.
(D)
A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the
nasogastric tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - ANSWER-B.
Reposition the client on her side. (The immediate priority is to determine if the
,tube is functioning correctly, which would then relieve the client's nausea. The
least invasive intervention (B) should be attempted first, followed by (A and C),
unless either of these interventions is contraindicated. If these measures are
unsuccessful, the client may require an antiemetic (D))
A hospitalized male client is receiving nasogastric tube feedings via a small-bore
tube and a continuous pump infusion. He reports that he had a bad bout of severe
coughing a few minutes ago, but feels fine now. What action is best for the nurse
to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the
HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
the tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.
- ANSWER-C. After clearing the tube with 30 ml of air, check the pH of fluid
withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - ANSWER-D. is disoriented to place and time
(The client is exhibiting disorientation (D). (A) refers to memory of the distant
past. The client is able to express himself without difficulty (B), and does not
demonstrate diminished attention span. (C).
, A client with chronic kidney disease (CKD) selects a scrambled egg for his
breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. -
ANSWER-A. Commend the client for selecting a high biologic value protein. (Foods
such as eggs and milk (A) are high biologic proteins which are allowed because
they are complete proteins and supply the essential amino acids that are
necessary for growth and cell repair. Orange juice is rich in potassium and should
not be encouraged. The client has made a good diet choice so (D) is not
necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to
realize that the center of gravity for an elderly person is the-- - ANSWER-Upper
torso (The center of gravity for adults is the hips. However, as the person grows
older, a stooped posture is common because of the changes from osteoporosis
and normal bone degeneration, and the knees, hips, and elbows flex. This stooped
posture results in the upper torso becoming the center of gravity for older
persons.)
In developing a plan of care for a client with dementia, the nurse should
remember that confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
