HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
1. An elderly client with a fractured D. Gently lift the client when moving into a desired
left hip is on strict bedrest. Which position.
nursing measure is essential to the
client's nursing care? To avoid shearing forces when repositioning, the
client should be lifted gently across a surface (D).
A. Massage any reddened areas for Reddened areas should not be massaged (A) since
at least five minutes. this may increase the damage to already traumatized
B. Encourage active range of mo- skin. To control pain and muscle spasms, active range
tion exercises on extremities. of motion (B) may be limited on the affected leg. The
C. Position the client laterally, position described in (C) is contraindicated for a client
prone, and dorsally in sequence. with a fractured left hip.
D. Gently lift the client when moving
into a desired position.
2. The nurse is administering medica- B. Flush the tube with water.
tions through a nasogastric tube
(NGT) which is connected to suc- The NGT should be flushed before, after and in be-
tion. After ensuring correct tube tween each medication administered (B). Once all
placement, what action should the medications are administered, the NGT should be
nurse take next? clamped for 20 minutes (A). (C and D) may be imple-
mented only after the tubing has been flushed.
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as
prescribed.
D. Crush the tablets and dissolve in
sterile water.
3. A client who is in hospice care A. Give an around-the-clock schedule for administra-
complains of increasing amounts tion of analgesics.
of pain. The healthcare provider
prescribes an analgesic every four The most effective management of pain is achieved
, HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
hours as needed. Which action using an around-the-clock schedule that provides
should the nurse implement? analgesic medications on a regular basis (A) and in
a timely manner. Analgesics are less effective if pain
A. Give an around-the-clock sched- persists until it is severe, so an analgesic medication
ule for administration of anal- should be administered before the client's pain peaks
gesics. (B). Providing comfort is a priority for the client who
B. Administer analgesic medication is dying, but sedation that impairs the client's ability
as needed when the pain is severe. to interact and experience the time before life ends
C. Provide medication to keep the should be minimized (C). Offering a medication-free
client sedated and unaware of stim- period allows the serum drug level to fall, which is not
uli. an effective method to manage chronic pain (D).
D. Offer a medication-free period so
that the client can do daily activities.
4. When assessing a client with wrist A. Loosen the right wrist restraint.
restraints, the nurse observes that
the fingers on the right hand are The priority nursing action is to restore circulation
blue. What action should the nurse by loosening the restraint (A), because blue fingers
implement first? (cyanosis) indicates decreased circulation. (C and D)
are also important nursing interventions, but do not
A. Loosen the right wrist restraint. have the priority of (A). Pulse oximetry (B) measures
B. Apply a pulse oximeter to the the saturation of hemoglobin with oxygen and is not
right hand. indicated in situations where the cyanosis is related to
C. Compare hand color bilaterally. mechanical compression (the restraints).
D. Palpate the right radial pulse.
5. The nurse is assessing the nu- B. A lactating woman nursing her 3-day-old infant.
tritional status of several clients.
Which client has the greatest nutri- A lactating woman (B) has the greatest need for addi-
tional need for additional intake of tional protein intake. (A, C, and D) are all conditions
protein? that require protein, but do not have the increased
metabolic protein demands of lactation.
A. A college-age track runner with a
, HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
sprained ankle.
B. A lactating woman nursing her
3-day-old infant.
C. A school-aged child with Type 2
diabetes.
D. An elderly man being treated for
a peptic ulcer.
6. A client is in the radiology depart- D. Give the missed dose at 1300 and change the
ment at 0900 when the prescription schedule to administer daily at 1300.
levofloxacin (Levaquin) 500 mg IV
q24h is scheduled to be adminis- To ensure that a therapeutic level of medication is
maintained, the nurse should administer the missed
tered. The client returns to the unit
at 1300. What is the best interven- dose as soon as possible, and revise the adminis-
tion for the nurse to implement? tration schedule accordingly to prevent dangerously
increasing the level of the medication in the blood-
A. Contact the healthcare provider stream (D). The nurse should document the reason
and complete a medication vari- for the late dose, but (A and C) are not warranted. (B)
ance form. could result in increased blood levels of the drug.
B. Administer the Levaquin at 1300
and resume the 0900 schedule in
the morning.
C. Notify the charge nurse and com-
plete an incident report to explain
the missed dose.
D. Give the missed dose at 1300 and
change the schedule to administer
daily at 1300.
7. While instructing a male client's A. Acknowledge that she is supporting the arm cor-
wife in the performance of pas- rectly.
sive range-of-motion exercises to
, HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
his contracted shoulder, the nurse The wife is performing the passive ROM correctly,
observes that she is holding his arm therefore the nurse should acknowledge this fact (A).
above and below the elbow. What The joint that is being exercised should be uncovered
nursing action should the nurse im- (B) while the rest of the body should remain covered
plement? for warmth and privacy. (C and D) do not provide
adequate support to the joint while still allowing for
A. Acknowledge that she is support- joint movement.
ing the arm correctly.
B. Encourage her to keep the joint
covered to maintain warmth.
C. Reinforce the need to grip direct-
ly under the joint for better sup-
port.
D. Instruct her to grip directly over
the joint for better motion.
8. What is the most important reason B. A decreased flow rate could result in the formation
for starting intravenous infusions in of a thrombosis.
the upper extremities rather than
the lower extremities of adults? Venous return is usually better in the upper extremi-
ties. Cannulation of the veins in the lower extremities
A. It is more difficult to find a super- increases the risk of thrombus formation (B) which, if
ficial vein in the feet and ankles. dislodged, could be life-threatening. Superficial veins
B. A decreased flow rate could re- are often very easy (A) to find in the feet and legs.
sult in the formation of a thrombo- Handling a leg or foot with an IV (C) is probably not
sis. any more difficult than handling an arm or hand. Even
C. A cannulated extremity is more if the nurse did believe moving a cannulated leg was
difficult to move when the leg or more difficult, this is not the most important reason
foot is used. for using the upper extremities. Pain (D) is not a con-
D. Veins are located deep in the sideration.
feet and ankles, resulting in a more
painful procedure.
Study online at https://quizlet.com/_9wybsl
1. An elderly client with a fractured D. Gently lift the client when moving into a desired
left hip is on strict bedrest. Which position.
nursing measure is essential to the
client's nursing care? To avoid shearing forces when repositioning, the
client should be lifted gently across a surface (D).
A. Massage any reddened areas for Reddened areas should not be massaged (A) since
at least five minutes. this may increase the damage to already traumatized
B. Encourage active range of mo- skin. To control pain and muscle spasms, active range
tion exercises on extremities. of motion (B) may be limited on the affected leg. The
C. Position the client laterally, position described in (C) is contraindicated for a client
prone, and dorsally in sequence. with a fractured left hip.
D. Gently lift the client when moving
into a desired position.
2. The nurse is administering medica- B. Flush the tube with water.
tions through a nasogastric tube
(NGT) which is connected to suc- The NGT should be flushed before, after and in be-
tion. After ensuring correct tube tween each medication administered (B). Once all
placement, what action should the medications are administered, the NGT should be
nurse take next? clamped for 20 minutes (A). (C and D) may be imple-
mented only after the tubing has been flushed.
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as
prescribed.
D. Crush the tablets and dissolve in
sterile water.
3. A client who is in hospice care A. Give an around-the-clock schedule for administra-
complains of increasing amounts tion of analgesics.
of pain. The healthcare provider
prescribes an analgesic every four The most effective management of pain is achieved
, HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
hours as needed. Which action using an around-the-clock schedule that provides
should the nurse implement? analgesic medications on a regular basis (A) and in
a timely manner. Analgesics are less effective if pain
A. Give an around-the-clock sched- persists until it is severe, so an analgesic medication
ule for administration of anal- should be administered before the client's pain peaks
gesics. (B). Providing comfort is a priority for the client who
B. Administer analgesic medication is dying, but sedation that impairs the client's ability
as needed when the pain is severe. to interact and experience the time before life ends
C. Provide medication to keep the should be minimized (C). Offering a medication-free
client sedated and unaware of stim- period allows the serum drug level to fall, which is not
uli. an effective method to manage chronic pain (D).
D. Offer a medication-free period so
that the client can do daily activities.
4. When assessing a client with wrist A. Loosen the right wrist restraint.
restraints, the nurse observes that
the fingers on the right hand are The priority nursing action is to restore circulation
blue. What action should the nurse by loosening the restraint (A), because blue fingers
implement first? (cyanosis) indicates decreased circulation. (C and D)
are also important nursing interventions, but do not
A. Loosen the right wrist restraint. have the priority of (A). Pulse oximetry (B) measures
B. Apply a pulse oximeter to the the saturation of hemoglobin with oxygen and is not
right hand. indicated in situations where the cyanosis is related to
C. Compare hand color bilaterally. mechanical compression (the restraints).
D. Palpate the right radial pulse.
5. The nurse is assessing the nu- B. A lactating woman nursing her 3-day-old infant.
tritional status of several clients.
Which client has the greatest nutri- A lactating woman (B) has the greatest need for addi-
tional need for additional intake of tional protein intake. (A, C, and D) are all conditions
protein? that require protein, but do not have the increased
metabolic protein demands of lactation.
A. A college-age track runner with a
, HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
sprained ankle.
B. A lactating woman nursing her
3-day-old infant.
C. A school-aged child with Type 2
diabetes.
D. An elderly man being treated for
a peptic ulcer.
6. A client is in the radiology depart- D. Give the missed dose at 1300 and change the
ment at 0900 when the prescription schedule to administer daily at 1300.
levofloxacin (Levaquin) 500 mg IV
q24h is scheduled to be adminis- To ensure that a therapeutic level of medication is
maintained, the nurse should administer the missed
tered. The client returns to the unit
at 1300. What is the best interven- dose as soon as possible, and revise the adminis-
tion for the nurse to implement? tration schedule accordingly to prevent dangerously
increasing the level of the medication in the blood-
A. Contact the healthcare provider stream (D). The nurse should document the reason
and complete a medication vari- for the late dose, but (A and C) are not warranted. (B)
ance form. could result in increased blood levels of the drug.
B. Administer the Levaquin at 1300
and resume the 0900 schedule in
the morning.
C. Notify the charge nurse and com-
plete an incident report to explain
the missed dose.
D. Give the missed dose at 1300 and
change the schedule to administer
daily at 1300.
7. While instructing a male client's A. Acknowledge that she is supporting the arm cor-
wife in the performance of pas- rectly.
sive range-of-motion exercises to
, HESI PN Fundamentals
Study online at https://quizlet.com/_9wybsl
his contracted shoulder, the nurse The wife is performing the passive ROM correctly,
observes that she is holding his arm therefore the nurse should acknowledge this fact (A).
above and below the elbow. What The joint that is being exercised should be uncovered
nursing action should the nurse im- (B) while the rest of the body should remain covered
plement? for warmth and privacy. (C and D) do not provide
adequate support to the joint while still allowing for
A. Acknowledge that she is support- joint movement.
ing the arm correctly.
B. Encourage her to keep the joint
covered to maintain warmth.
C. Reinforce the need to grip direct-
ly under the joint for better sup-
port.
D. Instruct her to grip directly over
the joint for better motion.
8. What is the most important reason B. A decreased flow rate could result in the formation
for starting intravenous infusions in of a thrombosis.
the upper extremities rather than
the lower extremities of adults? Venous return is usually better in the upper extremi-
ties. Cannulation of the veins in the lower extremities
A. It is more difficult to find a super- increases the risk of thrombus formation (B) which, if
ficial vein in the feet and ankles. dislodged, could be life-threatening. Superficial veins
B. A decreased flow rate could re- are often very easy (A) to find in the feet and legs.
sult in the formation of a thrombo- Handling a leg or foot with an IV (C) is probably not
sis. any more difficult than handling an arm or hand. Even
C. A cannulated extremity is more if the nurse did believe moving a cannulated leg was
difficult to move when the leg or more difficult, this is not the most important reason
foot is used. for using the upper extremities. Pain (D) is not a con-
D. Veins are located deep in the sideration.
feet and ankles, resulting in a more
painful procedure.
