HESI Fundamentals
V.2 EXAM
COMPLETE
QUESTIONS AND
VERIFIED
SOLUTIONS WITH
RATIONALE LATEST
UPDATE THIS YEAR
Which nutritional assessment data
should the nurse collect to best reflect
total muscle mass in an adolescent?
A) Height in inches or centimeters.
B) Weight in kilograms or pounds.
1
,C) Triceps skin fold thickness.
D) Upper arm circumference.
D) Upper arm circumference.
Upper arm circumference (D) is an
indirect measure of muscle mass. (A
and B) do not distinguish between fat
(adipose) and muscularity. (C) is a
measure of body fat.
An older client who is a resident in a
long term care facility has been
bedridden for a week. Which finding
should the nurse identify as a client
risk factor for pressure ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower
extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and
skin fold regions.
2
,D) Rashes in the axillary, groin, and
skin fold regions.
Immobility, constant contact with bed
clothing, and excessive heat and
moisture in areas where air flow is
limited contributes to bacterial and
fungal growth, which increases the
risk for rashes (D), skin breakdown,
and the development of pressure
ulcers. (A, B, and C) do not address
the concepts of inflammation and
tissue integrity.
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?
A) Adequate venous blood flow to the
lower extremities.
B) Estimated amount of body fat by an
underarm skinfold.
3
, C) Degree of flexion and extension of
the client's knee joint.
D) Change in the circumference of the
joint in centimeters.
C) Degree of flexion and extension of
the client's knee joint.
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 (C). A doppler is
used to measure blood flow (A).
Calipers are used to measure body fat
(B). A tape measure is used to
measure circumference of body parts
(D).
During a physical assessment, a
female client begins to cry. Which
action is best for the nurse to take?
4
V.2 EXAM
COMPLETE
QUESTIONS AND
VERIFIED
SOLUTIONS WITH
RATIONALE LATEST
UPDATE THIS YEAR
Which nutritional assessment data
should the nurse collect to best reflect
total muscle mass in an adolescent?
A) Height in inches or centimeters.
B) Weight in kilograms or pounds.
1
,C) Triceps skin fold thickness.
D) Upper arm circumference.
D) Upper arm circumference.
Upper arm circumference (D) is an
indirect measure of muscle mass. (A
and B) do not distinguish between fat
(adipose) and muscularity. (C) is a
measure of body fat.
An older client who is a resident in a
long term care facility has been
bedridden for a week. Which finding
should the nurse identify as a client
risk factor for pressure ulcers?
A) Generalized dry skin.
B) Localized dry skin on lower
extremities.
C) Red flush over entire skin surface.
D) Rashes in the axillary, groin, and
skin fold regions.
2
,D) Rashes in the axillary, groin, and
skin fold regions.
Immobility, constant contact with bed
clothing, and excessive heat and
moisture in areas where air flow is
limited contributes to bacterial and
fungal growth, which increases the
risk for rashes (D), skin breakdown,
and the development of pressure
ulcers. (A, B, and C) do not address
the concepts of inflammation and
tissue integrity.
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?
A) Adequate venous blood flow to the
lower extremities.
B) Estimated amount of body fat by an
underarm skinfold.
3
, C) Degree of flexion and extension of
the client's knee joint.
D) Change in the circumference of the
joint in centimeters.
C) Degree of flexion and extension of
the client's knee joint.
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 (C). A doppler is
used to measure blood flow (A).
Calipers are used to measure body fat
(B). A tape measure is used to
measure circumference of body parts
(D).
During a physical assessment, a
female client begins to cry. Which
action is best for the nurse to take?
4
