HESI FUNDAMENTALS PRACTICE
EXAM
The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first? A. Observe the
appearance of the skin under the ice pack. B. Instruct the client regarding the need
for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client
how long the ice was applied to the skin. -correct answer_Observe the appearance of
the skin under the ice pack (The first action taken by the nurse should be to assess
the skin for any possible thermal injury. If no injury to the skin has occurred, the
nurse can take the other actions.) The nurse mixes 50 mg of Nipride in 250 mL of
D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client
weighting 182 lbs. Using a drip factor of 60 gtt/mL, how many drops per minute
should the client receive? -correct answer_124 gtt/min The healthcare provider
prescribes an IV infusion of 1000 ml of Ringer's Lactate w/ 30 units of Pitocin to run
in over 4 hours for a client who has just delivered a 10 pound infant by cesarean
section. The tubing has been changed to a 20 gtt/ml administration set. The nurse
plans to set the flow rate at how many gtt/min? -correct answer_83 gtt/min Which
assessment data provides the most accurate determination of proper placement of a
nasogastric tube? -correct answer_Examining a chest x-ray obtained after the tubing
was inserted Three days following a surgery, a male client observes his colostomy for
the first time. He becomes quite upset and tells the nurse that it is much bigger than
he expected. What is the best response by the nurse? A. Reassure the client that he
will become accustomed to the stoma appearance in time. B. Instruct the client that
the stoma will become much smaller when the initial swelling diminishes. C. Offer to
contact a member of the local ostomy support group to help him with his concerns. D.
Encourage the client to handle the stoma equipment to gain confidence with the
procedure. -correct answer_B. Instruct the client that the stoma will become smaller
when the initial swelling diminishes (Postoperative swelling causes enlargement of
the stoma. The nurse can teach the client that the stoma will become smaller when
swelling is diminished (B). This will help reduce the client's anxiety and promote
acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is
a useful action, and may be taken after the nurse provides pertinent teaching. The
client is not yet demonstrating readiness to learn colostomy care. (D) 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. -correct 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)) 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. -correct answer_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
-correct answer_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.
-correct answer_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-- -correct answer_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 -correct answer_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 -correct answer_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?" -correct answer_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
EXAM
The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first? A. Observe the
appearance of the skin under the ice pack. B. Instruct the client regarding the need
for the covering. C. Reapply the covering after filling with fresh ice. D. Ask the client
how long the ice was applied to the skin. -correct answer_Observe the appearance of
the skin under the ice pack (The first action taken by the nurse should be to assess
the skin for any possible thermal injury. If no injury to the skin has occurred, the
nurse can take the other actions.) The nurse mixes 50 mg of Nipride in 250 mL of
D5W and plans to administer the solution at a rate of 5 mcg/kg/min to a client
weighting 182 lbs. Using a drip factor of 60 gtt/mL, how many drops per minute
should the client receive? -correct answer_124 gtt/min The healthcare provider
prescribes an IV infusion of 1000 ml of Ringer's Lactate w/ 30 units of Pitocin to run
in over 4 hours for a client who has just delivered a 10 pound infant by cesarean
section. The tubing has been changed to a 20 gtt/ml administration set. The nurse
plans to set the flow rate at how many gtt/min? -correct answer_83 gtt/min Which
assessment data provides the most accurate determination of proper placement of a
nasogastric tube? -correct answer_Examining a chest x-ray obtained after the tubing
was inserted Three days following a surgery, a male client observes his colostomy for
the first time. He becomes quite upset and tells the nurse that it is much bigger than
he expected. What is the best response by the nurse? A. Reassure the client that he
will become accustomed to the stoma appearance in time. B. Instruct the client that
the stoma will become much smaller when the initial swelling diminishes. C. Offer to
contact a member of the local ostomy support group to help him with his concerns. D.
Encourage the client to handle the stoma equipment to gain confidence with the
procedure. -correct answer_B. Instruct the client that the stoma will become smaller
when the initial swelling diminishes (Postoperative swelling causes enlargement of
the stoma. The nurse can teach the client that the stoma will become smaller when
swelling is diminished (B). This will help reduce the client's anxiety and promote
acceptance of the colostomy. (A) does not provide helpful teaching or support. (C) is
a useful action, and may be taken after the nurse provides pertinent teaching. The
client is not yet demonstrating readiness to learn colostomy care. (D) 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. -correct 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)) 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. -correct answer_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
-correct answer_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.
-correct answer_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-- -correct answer_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 -correct answer_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 -correct answer_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?" -correct answer_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
