FUNDAMENTAL HESI LATEST EXAMS TEST PAPER
QUESTIONS AND ANSWERS SURE A+
✔✔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. - ✔✔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,C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the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. -
✔✔C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the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 - ✔✔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. - ✔✔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-- - ✔✔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
D. can be prevented with adequate sleep - ✔✔B. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests
itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for
confusion.)
, ✔✔A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - ✔✔C. demonstrates the wound care
procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the
client's ability to perform a task, while (A and B) are subjective measures. (D) is
important, but is less of a priority than the the nurse's assessment of the client's ability
to complete wound care.)
✔✔A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the preoperative
assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?" - ✔✔B. "What vitamin and mineral
supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the
operative period. (A and C) are appropriate questions for long-term dietary counseling.
The nature of the surgery and anesthesia will determine the need for a clear liquid diet
(D), rather than the client's preference.)
✔✔During the initial morning assessment, a male client denies dysuria but reports that
his urine appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ✔✔D. Encourage additional
oral intake of juices and water.
✔✔Which intervention is most important for the nurse to implement for a male client
who is experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - ✔✔D. Assess the bladder for distention (Urinary
retention is the inability to void all urine collected in the bladder, which leads to
uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of
a client with urinary incontinence. (C) may worsen the bladder distention.)
QUESTIONS AND ANSWERS SURE A+
✔✔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. - ✔✔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. -
✔✔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 - ✔✔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. - ✔✔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-- - ✔✔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
D. can be prevented with adequate sleep - ✔✔B. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests
itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for
confusion.)
, ✔✔A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - ✔✔C. demonstrates the wound care
procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the
client's ability to perform a task, while (A and B) are subjective measures. (D) is
important, but is less of a priority than the the nurse's assessment of the client's ability
to complete wound care.)
✔✔A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the preoperative
assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?" - ✔✔B. "What vitamin and mineral
supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the
operative period. (A and C) are appropriate questions for long-term dietary counseling.
The nature of the surgery and anesthesia will determine the need for a clear liquid diet
(D), rather than the client's preference.)
✔✔During the initial morning assessment, a male client denies dysuria but reports that
his urine appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ✔✔D. Encourage additional
oral intake of juices and water.
✔✔Which intervention is most important for the nurse to implement for a male client
who is experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - ✔✔D. Assess the bladder for distention (Urinary
retention is the inability to void all urine collected in the bladder, which leads to
uncomfortable bladder distention (D). (A and B) are useful actions to protect the skin of
a client with urinary incontinence. (C) may worsen the bladder distention.)
