HESI RN FUNDAMENTALS TEST 18 EXAM
REVIEW SOLVED QUESTIONS WITH ACCURATE
ANSWERS
◉ 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 healthcare provider.
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withdrawn from the tube.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fluid withdrawn from the tube
Coughing, vomiting, and suctioning can precipitate displacement of
the tip of the small bore feeding tube upward into the esophagus,
placing the client at increased risk for aspiration. Checking the
sample of fluid withdrawn from the tube (after clearing the tube
,with 30 ml of air) for acidic (stomach) or alkaline (intestine) values
is a more sensitive method for these tubes, and the nurse should
assess tube placement in this way prior to taking any other action
(C). (A and B) are not indicated. The auscultating method (D) has
been found to be unreliable for small-bore feeding tubes.
◉ 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).
,◉ The UAPs working on a chronic neuro unit ask the nurse to help
them determine the safest way to transfer an elderly client with left-
sided weakness from the bed to the chair. What method describes
the correct transfer procedure for this client?
A) Place the chair at a right angle to the bed on the client's left side
before moving.
B) Assist the client to a standing position, then place the right hand
on the armrest.
C) Have the client place the left foot next to the chair and pivot to the
left before sitting.
D) Move the chair parallel to the right side of the bed, and stand the
client on the right foot
Answer: D) Move the chair parallel to the right side of the bed, and
stand the client on the right foot
(D) uses the client's stronger side, the right side, for weight-bearing
during the transfer, and is the safest approach to take. (A, B, and C)
are unsafe methods of transfer and include the use of poor body
mechanics by the caregiver.
◉ When conducting an admission assessment, the nurse should ask
the client about the use of complimentary healing practices. Which
statement is accurate regarding the use of these practices?
, A) Complimentary healing practices interfere with the efficacy of the
medical model of treatment.
B) Conventional medications are likely to interact with folk remedies
and cause adverse effects.
C) Many complimentary healing practices can be used in conjunction
with conventional practices.
D) Conventional medical practices will ultimately replace the use of
complimentary healing practices.
Answer: C) Many complimentary healing practices can be used in
conjunction with conventional practices
Conventional approaches to health care can be depersonalizing and
often fail to take into consideration all aspects of an individual,
including body, mind, and spirit. Often complimentary healing
practices can be used in conjunction with conventional medical
practices (C), rather than interfering (A) with conventional practices,
causing adverse effects (B), or replacing conventional medical care
(D).
◉ After completing an assessment and determining that a client has
a problem, which action should the nurse perform next?
A) Determine the etiology of the problem.
B) Prioritize nursing care interventions.
C) Plan appropriate interventions.
REVIEW SOLVED QUESTIONS WITH ACCURATE
ANSWERS
◉ 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 healthcare provider.
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
Coughing, vomiting, and suctioning can precipitate displacement of
the tip of the small bore feeding tube upward into the esophagus,
placing the client at increased risk for aspiration. Checking the
sample of fluid withdrawn from the tube (after clearing the tube
,with 30 ml of air) for acidic (stomach) or alkaline (intestine) values
is a more sensitive method for these tubes, and the nurse should
assess tube placement in this way prior to taking any other action
(C). (A and B) are not indicated. The auscultating method (D) has
been found to be unreliable for small-bore feeding tubes.
◉ 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).
,◉ The UAPs working on a chronic neuro unit ask the nurse to help
them determine the safest way to transfer an elderly client with left-
sided weakness from the bed to the chair. What method describes
the correct transfer procedure for this client?
A) Place the chair at a right angle to the bed on the client's left side
before moving.
B) Assist the client to a standing position, then place the right hand
on the armrest.
C) Have the client place the left foot next to the chair and pivot to the
left before sitting.
D) Move the chair parallel to the right side of the bed, and stand the
client on the right foot
Answer: D) Move the chair parallel to the right side of the bed, and
stand the client on the right foot
(D) uses the client's stronger side, the right side, for weight-bearing
during the transfer, and is the safest approach to take. (A, B, and C)
are unsafe methods of transfer and include the use of poor body
mechanics by the caregiver.
◉ When conducting an admission assessment, the nurse should ask
the client about the use of complimentary healing practices. Which
statement is accurate regarding the use of these practices?
, A) Complimentary healing practices interfere with the efficacy of the
medical model of treatment.
B) Conventional medications are likely to interact with folk remedies
and cause adverse effects.
C) Many complimentary healing practices can be used in conjunction
with conventional practices.
D) Conventional medical practices will ultimately replace the use of
complimentary healing practices.
Answer: C) Many complimentary healing practices can be used in
conjunction with conventional practices
Conventional approaches to health care can be depersonalizing and
often fail to take into consideration all aspects of an individual,
including body, mind, and spirit. Often complimentary healing
practices can be used in conjunction with conventional medical
practices (C), rather than interfering (A) with conventional practices,
causing adverse effects (B), or replacing conventional medical care
(D).
◉ After completing an assessment and determining that a client has
a problem, which action should the nurse perform next?
A) Determine the etiology of the problem.
B) Prioritize nursing care interventions.
C) Plan appropriate interventions.
