HESI FUNDAMENTALS PRACTICE
EXAM UPDATED Study Guide
QUESTIONS AND CORRECT ANSWERS
- 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 ANSWERS 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 ANSWERS 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
ANSWERS 83 gtt/min
,Which assessment data provides the most accurate determination of
proper placement of a nasogastric tube? - CORRECT ANSWERS
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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS
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 ANSWERS 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 ANSWERS 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.)
EXAM UPDATED Study Guide
QUESTIONS AND CORRECT ANSWERS
- 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 ANSWERS 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 ANSWERS 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
ANSWERS 83 gtt/min
,Which assessment data provides the most accurate determination of
proper placement of a nasogastric tube? - CORRECT ANSWERS
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 ANSWERS 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 ANSWERS 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 ANSWERS 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 ANSWERS
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 ANSWERS 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 ANSWERS 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.)
