ALL HESI Fundamentals Exam Test Bank updated
y y y y y y y
HESIyFundamentalsyExam,yAnswered
Anyelderlyyclientywithyayfracturedyleftyhipyisyonystrictybedrest.yWhichynursingymeasureyisyesse
ntialytoytheyclient'synursingycare?
A. Massageyanyyreddenedyareasyforyatyleastyfiveyminutes.
B. Encourageyactiveyrangeyofymotionyexercisesyonyextremities.
C. Positionytheyclientylaterally,yprone,yandydorsallyyinysequence.
D. Gentlyyliftytheyclientywhenymovingyintoyaydesiredyposition.y-
yToyavoidyshearingyforcesywhenyrepositioning,ytheyclientyshouldybeyliftedygentlyyacrossyays
urfacey(D).yReddenedyareasyshouldynotybeymassagedy(A)ysinceythisymayyincreaseytheydam
ageytoyalreadyytraumatizedyskin.yToycontrolypainyandymuscleyspasms,yactiveyrangeyofymoti
ony(B)ymayybeylimitedyonytheyaffectedyleg.yTheypositionydescribedyiny(C)yisycontraindicate
dyforyayclientywithyayfracturedyleftyhip.
CorrectyAnswer:yD
Theynurseyisyadministeringymedicationsythroughyaynasogastricytubey(NGT)ywhichyisyconne
ctedytoysuction.yAfteryensuringycorrectytubeyplacement,ywhatyactionyshouldytheynurseytakey
next?
A. Clampytheytubeyfory20yminutes.
B. Flushytheytubeywithywater.
,C. Administerytheymedicationsyasyprescribed.
D. Crushytheytabletsyandydissolveyinysterileywater.y-
yTheyNGTyshouldybeyflushedybefore,yafteryandyinybetweenyeachymedicationyadministered
y(B).yOnceyallymedicationsyareyadministered,ytheyNGTyshouldybeyclampedyfory20yminute
sy(A).y(CyandyD)ymayybeyimplementedyonlyyafterytheytubingyhasybeenyflushed.
CorrectyAnswer:yB
Ayclientywhoyisyinyhospiceycareycomplainsyofyincreasingyamountsyofypain.yTheyhealthcarey
provideryprescribesyanyanalgesicyeveryyfouryhoursyasyneeded.yWhichyactionyshouldytheynur
seyimplement?
A. Giveyanyaround-the-clockyscheduleyforyadministrationyofyanalgesics.
B. Administeryanalgesicymedicationyasyneededywhenytheypainyisysevere.
C. Provideymedicationytoykeepytheyclientysedatedyandyunawareyofystimuli.
D. Offeryaymedication-freeyperiodysoythatytheyclientycanydoydailyyactivities.y-
yTheymostyeffectiveymanagementyofypainyisyachievedyusingyanyaround-the-
clockyscheduleythatyprovidesyanalgesicymedicationsyonyayregularybasisy(A)yandyinyaytimelyy
manner.yAnalgesicsyareylessyeffectiveyifypainypersistsyuntilyityisysevere,ysoyanyanalgesicyme
dicationyshouldybeyadministeredybeforeytheyclient'sypainypeaksy(B).yProvidingycomfortyisya
y priorityyforytheyclientywhoyisydying,ybutysedationythatyimpairsytheyclient'syabilityytoyinterac
tyandyexperienceytheytimeybeforeylifeyendsyshouldybeyminimizedy(C).yOfferingyaymedicatio
n-
freeyperiodyallowsytheyserumydrugylevelytoyfall,ywhichyisynotyanyeffectiveymethodytoymanag
eychronicypainy(D).
,CorrectyAnswer:yA
Whenyassessingyayclientywithywristyrestraints,ytheynurseyobservesythatytheyfingersyonytheyri
ghtyhandyareyblue.yWhatyactionyshouldytheynurseyimplementyfirst?
A. Loosenytheyrightywristyrestraint.
B. Applyyaypulseyoximeterytoytheyrightyhand.
C. Compareyhandycolorybilaterally.
D. Palpateytheyrightyradialypulse.y-
yTheypriorityynursingyactionyisytoyrestoreycirculationybyylooseningytheyrestrainty(A),ybecaus
eyblueyfingersy(cyanosis)yindicatesydecreasedycirculation.y(CyandyD)yareyalsoyimportantynu
rsingyinterventions,ybutydoynotyhaveytheypriorityyofy(A).yPulseyoximetryy(B)ymeasuresythey
saturationyofyhemoglobinywithyoxygenyandyisynotyindicatedyinysituationsywhereytheycyanos
isyisyrelatedytoymechanicalycompressiony(theyrestraints).
CorrectyAnswer:yA
Theynurseyisyassessingytheynutritionalystatusyofyseveralyclients.yWhichyclientyhasytheygreate
stynutritionalyneedyforyadditionalyintakeyofyprotein?
A. Aycollege-ageytrackyrunnerywithyaysprainedyankle.
B. Aylactatingywomanynursingyhery3-day-oldyinfant.
C. Ayschool-agedychildywithyTypey2ydiabetes.
, D. Anyelderlyymanybeingytreatedyforyaypepticyulcer.y-
yAylactatingywomany(B)yhasytheygreatestyneedyforyadditionalyproteinyintake.y(A,yC,yandyD
)yareyallyconditionsythatyrequireyprotein,ybutydoynotyhaveytheyincreasedymetabolicyproteiny
demandsyofylactation.
CorrectyAnswer:yB
Ayclientyisyinytheyradiologyydepartmentyaty0900ywhenytheyprescriptionylevofloxaciny(Leva
quin)y500ymgyIVyq24hyisyscheduledytoybeyadministered.yTheyclientyreturnsytoytheyunityaty13
00.yWhatyisytheybestyinterventionyforytheynurseytoyimplement?
A. Contactytheyhealthcareyprovideryandycompleteyaymedicationyvarianceyform.
B. AdministerytheyLevaquinyaty1300yandyresumeythey0900yscheduleyinytheymorning.
C. Notifyytheychargeynurseyandycompleteyanyincidentyreportytoyexplainytheymissedydose.
D. Giveytheymissedydoseyaty1300yandychangeytheyscheduleytoyadministerydailyyaty1300.y-
yToyensureythatyaytherapeuticylevelyofymedicationyisymaintained,ytheynurseyshouldyadminist
erytheymissedydoseyasysoonyasypossible,yandyreviseytheyadministrationyscheduleyaccordingl
yytoypreventydangerouslyyincreasingytheylevelyofytheymedicationyinytheybloodstreamy(D).yT
heynurseyshouldydocumentytheyreasonyforytheylateydose,ybuty(AyandyC)yareynotywarranted.y(
B)ycouldyresultyinyincreasedybloodylevelsyofytheydrug.
CorrectyAnswer:yD
Whileyinstructingyaymaleyclient'sywifeyinytheyperformanceyofypassiveyrange-of-
motionyexercisesytoyhisycontractedyshoulder,ytheynurseyobservesythatysheyisyholdingyhisyar
myaboveyandybelowytheyelbow.yWhatynursingyactionyshouldytheynurseyimplement?
y y y y y y y
HESIyFundamentalsyExam,yAnswered
Anyelderlyyclientywithyayfracturedyleftyhipyisyonystrictybedrest.yWhichynursingymeasureyisyesse
ntialytoytheyclient'synursingycare?
A. Massageyanyyreddenedyareasyforyatyleastyfiveyminutes.
B. Encourageyactiveyrangeyofymotionyexercisesyonyextremities.
C. Positionytheyclientylaterally,yprone,yandydorsallyyinysequence.
D. Gentlyyliftytheyclientywhenymovingyintoyaydesiredyposition.y-
yToyavoidyshearingyforcesywhenyrepositioning,ytheyclientyshouldybeyliftedygentlyyacrossyays
urfacey(D).yReddenedyareasyshouldynotybeymassagedy(A)ysinceythisymayyincreaseytheydam
ageytoyalreadyytraumatizedyskin.yToycontrolypainyandymuscleyspasms,yactiveyrangeyofymoti
ony(B)ymayybeylimitedyonytheyaffectedyleg.yTheypositionydescribedyiny(C)yisycontraindicate
dyforyayclientywithyayfracturedyleftyhip.
CorrectyAnswer:yD
Theynurseyisyadministeringymedicationsythroughyaynasogastricytubey(NGT)ywhichyisyconne
ctedytoysuction.yAfteryensuringycorrectytubeyplacement,ywhatyactionyshouldytheynurseytakey
next?
A. Clampytheytubeyfory20yminutes.
B. Flushytheytubeywithywater.
,C. Administerytheymedicationsyasyprescribed.
D. Crushytheytabletsyandydissolveyinysterileywater.y-
yTheyNGTyshouldybeyflushedybefore,yafteryandyinybetweenyeachymedicationyadministered
y(B).yOnceyallymedicationsyareyadministered,ytheyNGTyshouldybeyclampedyfory20yminute
sy(A).y(CyandyD)ymayybeyimplementedyonlyyafterytheytubingyhasybeenyflushed.
CorrectyAnswer:yB
Ayclientywhoyisyinyhospiceycareycomplainsyofyincreasingyamountsyofypain.yTheyhealthcarey
provideryprescribesyanyanalgesicyeveryyfouryhoursyasyneeded.yWhichyactionyshouldytheynur
seyimplement?
A. Giveyanyaround-the-clockyscheduleyforyadministrationyofyanalgesics.
B. Administeryanalgesicymedicationyasyneededywhenytheypainyisysevere.
C. Provideymedicationytoykeepytheyclientysedatedyandyunawareyofystimuli.
D. Offeryaymedication-freeyperiodysoythatytheyclientycanydoydailyyactivities.y-
yTheymostyeffectiveymanagementyofypainyisyachievedyusingyanyaround-the-
clockyscheduleythatyprovidesyanalgesicymedicationsyonyayregularybasisy(A)yandyinyaytimelyy
manner.yAnalgesicsyareylessyeffectiveyifypainypersistsyuntilyityisysevere,ysoyanyanalgesicyme
dicationyshouldybeyadministeredybeforeytheyclient'sypainypeaksy(B).yProvidingycomfortyisya
y priorityyforytheyclientywhoyisydying,ybutysedationythatyimpairsytheyclient'syabilityytoyinterac
tyandyexperienceytheytimeybeforeylifeyendsyshouldybeyminimizedy(C).yOfferingyaymedicatio
n-
freeyperiodyallowsytheyserumydrugylevelytoyfall,ywhichyisynotyanyeffectiveymethodytoymanag
eychronicypainy(D).
,CorrectyAnswer:yA
Whenyassessingyayclientywithywristyrestraints,ytheynurseyobservesythatytheyfingersyonytheyri
ghtyhandyareyblue.yWhatyactionyshouldytheynurseyimplementyfirst?
A. Loosenytheyrightywristyrestraint.
B. Applyyaypulseyoximeterytoytheyrightyhand.
C. Compareyhandycolorybilaterally.
D. Palpateytheyrightyradialypulse.y-
yTheypriorityynursingyactionyisytoyrestoreycirculationybyylooseningytheyrestrainty(A),ybecaus
eyblueyfingersy(cyanosis)yindicatesydecreasedycirculation.y(CyandyD)yareyalsoyimportantynu
rsingyinterventions,ybutydoynotyhaveytheypriorityyofy(A).yPulseyoximetryy(B)ymeasuresythey
saturationyofyhemoglobinywithyoxygenyandyisynotyindicatedyinysituationsywhereytheycyanos
isyisyrelatedytoymechanicalycompressiony(theyrestraints).
CorrectyAnswer:yA
Theynurseyisyassessingytheynutritionalystatusyofyseveralyclients.yWhichyclientyhasytheygreate
stynutritionalyneedyforyadditionalyintakeyofyprotein?
A. Aycollege-ageytrackyrunnerywithyaysprainedyankle.
B. Aylactatingywomanynursingyhery3-day-oldyinfant.
C. Ayschool-agedychildywithyTypey2ydiabetes.
, D. Anyelderlyymanybeingytreatedyforyaypepticyulcer.y-
yAylactatingywomany(B)yhasytheygreatestyneedyforyadditionalyproteinyintake.y(A,yC,yandyD
)yareyallyconditionsythatyrequireyprotein,ybutydoynotyhaveytheyincreasedymetabolicyproteiny
demandsyofylactation.
CorrectyAnswer:yB
Ayclientyisyinytheyradiologyydepartmentyaty0900ywhenytheyprescriptionylevofloxaciny(Leva
quin)y500ymgyIVyq24hyisyscheduledytoybeyadministered.yTheyclientyreturnsytoytheyunityaty13
00.yWhatyisytheybestyinterventionyforytheynurseytoyimplement?
A. Contactytheyhealthcareyprovideryandycompleteyaymedicationyvarianceyform.
B. AdministerytheyLevaquinyaty1300yandyresumeythey0900yscheduleyinytheymorning.
C. Notifyytheychargeynurseyandycompleteyanyincidentyreportytoyexplainytheymissedydose.
D. Giveytheymissedydoseyaty1300yandychangeytheyscheduleytoyadministerydailyyaty1300.y-
yToyensureythatyaytherapeuticylevelyofymedicationyisymaintained,ytheynurseyshouldyadminist
erytheymissedydoseyasysoonyasypossible,yandyreviseytheyadministrationyscheduleyaccordingl
yytoypreventydangerouslyyincreasingytheylevelyofytheymedicationyinytheybloodstreamy(D).yT
heynurseyshouldydocumentytheyreasonyforytheylateydose,ybuty(AyandyC)yareynotywarranted.y(
B)ycouldyresultyinyincreasedybloodylevelsyofytheydrug.
CorrectyAnswer:yD
Whileyinstructingyaymaleyclient'sywifeyinytheyperformanceyofypassiveyrange-of-
motionyexercisesytoyhisycontractedyshoulder,ytheynurseyobservesythatysheyisyholdingyhisyar
myaboveyandybelowytheyelbow.yWhatynursingyactionyshouldytheynurseyimplement?
