Week 3 BSN 225 EAQ HESI
Practice Test Assessment
Performance Review – Questions
and Correct Answers with
Rationales/ BSN 225 HESI
Practice Questions and Correct
Detailed Answers
Evolve Hesi BSN 225 Nightingale
,5/25/25, 11:56 PM HESI
Return to Overview
Practice Test Assessment Performance
100%
Bravo!
Correct
Correct
An older client with a fractured left hip is on strict bedrest. Which
nursing measure is essential to the client's nursing care?
Massage any reddened areas for at least five minutes.
Encourage active range of motion exercises on extremities.
Position the client laterally, prone, and dorsally in sequence.
Gently lift the client when moving into a desired position.
Rationale
To avoid shearing forces when repositioning, the client should be lifted gently across a surface.
Reddened areas should not be massaged since this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.
1/39
,5/25/25, 11:56 PM HESI
During a visit to the outpatient clinic, the nurse assesses a client with
severe osteoarthritis using a goniometer. Which finding should the
nurse expect to measure?
Adequate venous blood flow to the lower extremities.
Estimated amount of body fat by an underarm skinfold.
Degree of flexion and extension of the client's knee joint.
Change in the circumference of the joint in centimeters.
Rationale
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring
device that is placed over a joint as the individual extends or flexes the joint to measure the degrees
of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood
flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of
body parts.
Which action is most important for the nurse to implement when
donning sterile gloves?
Maintain thumb at a ninety degree angle.
Hold hands with fingers down while gloving.
Keep gloved hands above the elbows.
Put the glove on the dominant hand first.
Rationale
Gloved hands held below waist level are considered unsterile. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis.
The nurse is assisting an 82-year-old client to ambulate. Which is the
center of gravity for an elderly person?
Arms.
Upper torso.
2/39
, 5/25/25, 11:56 PM HESI
Head.
Feet.
Rationale
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. Although arms are part, or an extension of the upper torso, this is not the best and
most complete answer.
Twenty minutes after beginning a heat application, the client states
that the heating pad no longer feels warm enough. What is the best
response by the nurse?
"That means you have derived the maximum benefit, and the heat can be
removed."
"Your blood vessels are becoming dilated and removing the heat from the
site."
"We will increase the temperature 5 degrees when the pad no longer feels
warm."
"The body's receptors adapt over time as they are exposed to heat."
Rationale
Thermal adaptation occurs 20 to 30 minutes after heat application. This means the client may not
feel the same level of heat as at the start of the treatment. The nurse should not increase the heat
setting.
When assessing a client with wrist restraints, the nurse observes that
the fingers on the right hand are blue. What action should the nurse
implement first?
Loosen the right wrist restraint.
Apply a pulse oximeter to the right hand.
3/39
Practice Test Assessment
Performance Review – Questions
and Correct Answers with
Rationales/ BSN 225 HESI
Practice Questions and Correct
Detailed Answers
Evolve Hesi BSN 225 Nightingale
,5/25/25, 11:56 PM HESI
Return to Overview
Practice Test Assessment Performance
100%
Bravo!
Correct
Correct
An older client with a fractured left hip is on strict bedrest. Which
nursing measure is essential to the client's nursing care?
Massage any reddened areas for at least five minutes.
Encourage active range of motion exercises on extremities.
Position the client laterally, prone, and dorsally in sequence.
Gently lift the client when moving into a desired position.
Rationale
To avoid shearing forces when repositioning, the client should be lifted gently across a surface.
Reddened areas should not be massaged since this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range of motion may be limited on the affected leg.
1/39
,5/25/25, 11:56 PM HESI
During a visit to the outpatient clinic, the nurse assesses a client with
severe osteoarthritis using a goniometer. Which finding should the
nurse expect to measure?
Adequate venous blood flow to the lower extremities.
Estimated amount of body fat by an underarm skinfold.
Degree of flexion and extension of the client's knee joint.
Change in the circumference of the joint in centimeters.
Rationale
The goniometer is a two-piece ruler that is jointed in the middle with a protractor-type measuring
device that is placed over a joint as the individual extends or flexes the joint to measure the degrees
of flexion and extension on the protractor. On the other hand, a doppler is used to measure blood
flow; calipers are used to measure body fat; and a tape measure is used to measure circumference of
body parts.
Which action is most important for the nurse to implement when
donning sterile gloves?
Maintain thumb at a ninety degree angle.
Hold hands with fingers down while gloving.
Keep gloved hands above the elbows.
Put the glove on the dominant hand first.
Rationale
Gloved hands held below waist level are considered unsterile. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis.
The nurse is assisting an 82-year-old client to ambulate. Which is the
center of gravity for an elderly person?
Arms.
Upper torso.
2/39
, 5/25/25, 11:56 PM HESI
Head.
Feet.
Rationale
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. Although arms are part, or an extension of the upper torso, this is not the best and
most complete answer.
Twenty minutes after beginning a heat application, the client states
that the heating pad no longer feels warm enough. What is the best
response by the nurse?
"That means you have derived the maximum benefit, and the heat can be
removed."
"Your blood vessels are becoming dilated and removing the heat from the
site."
"We will increase the temperature 5 degrees when the pad no longer feels
warm."
"The body's receptors adapt over time as they are exposed to heat."
Rationale
Thermal adaptation occurs 20 to 30 minutes after heat application. This means the client may not
feel the same level of heat as at the start of the treatment. The nurse should not increase the heat
setting.
When assessing a client with wrist restraints, the nurse observes that
the fingers on the right hand are blue. What action should the nurse
implement first?
Loosen the right wrist restraint.
Apply a pulse oximeter to the right hand.
3/39
