HESI Fundamentals Practice Test/Final 2 (NCLEX) new
actual 2023 test with complete solution
An adult is now alert and oriented following abdominal surgery. What position is
most appropriate for the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's
A
This position allows for greater thoracic expansion and puts less pressure on the suture
line
Following a craniotomy, the nurse positioned a client in low fowler's for which
reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload
B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia.
Which action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day
C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the
wheelchair. How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed
A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the
client?
a. Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position
A
Mr. Landon is to have a tracheostomy performed. What is the top nursing
priority?
a. Shave the neck
, b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV
B
Mr. Landon is to have a tracheostomy performed. Which nursing action is
essential during tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning
B--To prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions
is most appropriate for the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift
B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a
tracheostomy tube, the client starts to cough. What is the best action for the
nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions
D
During the suctioning of a tracheostomy tube, the catheter appears to attach to
the tracheal walls and creates a pulling sensation. What is the best action for the
nurse to take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper
A
Warm compresses are ordered for an open wound. Which action is appropriate
for the nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the
area when it cools down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing
A
The day after surgery in which a colostomy was performed, the client says "I
know the doctor did not really do a colostomy". The nurse understands that the
client is in an early stage of adjustment to the diagnosis or surgery, with nursing
actual 2023 test with complete solution
An adult is now alert and oriented following abdominal surgery. What position is
most appropriate for the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's
A
This position allows for greater thoracic expansion and puts less pressure on the suture
line
Following a craniotomy, the nurse positioned a client in low fowler's for which
reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload
B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia.
Which action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day
C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the
wheelchair. How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed
A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the
client?
a. Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position
A
Mr. Landon is to have a tracheostomy performed. What is the top nursing
priority?
a. Shave the neck
, b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV
B
Mr. Landon is to have a tracheostomy performed. Which nursing action is
essential during tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning
B--To prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions
is most appropriate for the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift
B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a
tracheostomy tube, the client starts to cough. What is the best action for the
nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions
D
During the suctioning of a tracheostomy tube, the catheter appears to attach to
the tracheal walls and creates a pulling sensation. What is the best action for the
nurse to take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper
A
Warm compresses are ordered for an open wound. Which action is appropriate
for the nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the
area when it cools down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing
A
The day after surgery in which a colostomy was performed, the client says "I
know the doctor did not really do a colostomy". The nurse understands that the
client is in an early stage of adjustment to the diagnosis or surgery, with nursing
