Hesi Fundamentals Practice Test
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1. An elderly client with a fractured left hip is on strict bedrest.Which nursingm
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easure is essential to the client's nursing care?
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A. Massage any reddened areas for at least five minutes.
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B. Encourage active range of motion exercises on extremities.k k k k k k k
C. Position the client laterally, prone, and dorsally in sequence.
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D. Gently lift the client when moving into a desired position.: To avoid shearingfor
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ces when repositioning, the client should be lifted gently across a surface (D). Redd
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ened areas should not be massaged (A) since this may increase the damageto alread
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y traumatized skin. To control pain and muscle spasms, active range of motion (B) m
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ay be limited on the affected leg. The position described in (C) is contraindicated for
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a client with a fractured left hip.
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Correct Answer: D k k
2. The nurse is administering medications through a nasogastric tube (NGT)w
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hich is connected to suction. After ensuring correct tube placement, whatacti
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on should the nurse take next?
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,A. Clamp the tube for 20 minutes. k k k k k
B. Flush the tube with water. k k k k
C. Administer the medications as prescribed. k k k k
D. Crush the tablets and dissolve in sterile water.: The NGT should be flushedbe
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fore, after and in between each medication administered (B). Once all medica-
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tions are administered, the NGT should be clamped for 20 minutes (A). (C and D)ma
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y be implemented only after the tubing has been flushed.
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Correct Answer: B k k
3. A client who is in hospice care complains of increasing amounts of pain.Th
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e healthcare provider prescribes an analgesic every four hours as needed.Whic
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h action should the nurse implement?
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A. Give an around-the-clock schedule for administration of analgesics.
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B. Administer analgesic medication as needed when the pain is severe.
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C. Provide medication to keep the client sedated and unaware of stimuli.
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D. Offer a medication-free period so that the client can do daily activities.-
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: The most effective management of pain is achieved using an around-the-
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clock schedule that provides analgesic medications on a regular basis (A) and in a ti
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2k/k25
,mely manner. Analgesics are less effective if pain persists until it is severe, so ananal
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gesic medication should be administered before the client's pain peaks (B).
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Providing comfort is a priority for the client who is dying, but sedation that impairsthe c
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lient's ability to interact and experience the time before life ends should be minimized
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(C). Offering a medication-free period allows the serum drug level to
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3k/k25
, fall, which is not an effective method to manage chronic pain (D).Correct A
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nswer: A k
4. When assessing a client with wrist restraints, the nurse observes that thefi
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ngers on the right hand are blue. What action should the nurse implementfirst
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?
A. Loosen the right wrist restraint. k k k k
B. Apply a pulse oximeter to the right hand.
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C. Compare hand color bilaterally. k k k
D. Palpate the right radial pulse.: The priority nursing action is to restore cir-
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kculation by loosening the restraint (A), because blue fingers (cyanosis) indicatesde
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creased circulation. (C and D) are also important nursing interventions, but do not
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have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin
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with oxygen and is not indicated in situations where the cyanosis isrelated to mech
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anical compression (the restraints).
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Correct Answer: A k k
5. The nurse is assessing the nutritional status of several clients. Whichcl
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ient has the greatest nutritional need for additional intake of protein?
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A. A college-age track runner with a sprained ankle.
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4k/k25
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1. An elderly client with a fractured left hip is on strict bedrest.Which nursingm
k k k k k k k k k k k k k k
easure is essential to the client's nursing care?
k k k k k k k
A. Massage any reddened areas for at least five minutes.
k k k k k k k k
B. Encourage active range of motion exercises on extremities.k k k k k k k
C. Position the client laterally, prone, and dorsally in sequence.
k k k k k k k k
D. Gently lift the client when moving into a desired position.: To avoid shearingfor
k k k k k k k k k k k k k
ces when repositioning, the client should be lifted gently across a surface (D). Redd
k k k k k k k k k k k k k
ened areas should not be massaged (A) since this may increase the damageto alread
k k k k k k k k k k k k k k
y traumatized skin. To control pain and muscle spasms, active range of motion (B) m
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ay be limited on the affected leg. The position described in (C) is contraindicated for
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a client with a fractured left hip.
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Correct Answer: D k k
2. The nurse is administering medications through a nasogastric tube (NGT)w
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hich is connected to suction. After ensuring correct tube placement, whatacti
k k k k k k k k k k k
on should the nurse take next?
k k k k k
1k/k25
,A. Clamp the tube for 20 minutes. k k k k k
B. Flush the tube with water. k k k k
C. Administer the medications as prescribed. k k k k
D. Crush the tablets and dissolve in sterile water.: The NGT should be flushedbe
k k k k k k k k k k k k k
fore, after and in between each medication administered (B). Once all medica-
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tions are administered, the NGT should be clamped for 20 minutes (A). (C and D)ma
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y be implemented only after the tubing has been flushed.
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Correct Answer: B k k
3. A client who is in hospice care complains of increasing amounts of pain.Th
k k k k k k k k k k k k k
e healthcare provider prescribes an analgesic every four hours as needed.Whic
k k k k k k k k k k k
h action should the nurse implement?
k k k k k
A. Give an around-the-clock schedule for administration of analgesics.
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B. Administer analgesic medication as needed when the pain is severe.
k k k k k k k k k
C. Provide medication to keep the client sedated and unaware of stimuli.
k k k k k k k k k k
D. Offer a medication-free period so that the client can do daily activities.-
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: The most effective management of pain is achieved using an around-the-
k k k k k k k k k k k
clock schedule that provides analgesic medications on a regular basis (A) and in a ti
k k k k k k k k k k k k k k
2k/k25
,mely manner. Analgesics are less effective if pain persists until it is severe, so ananal
k k k k k k k k k k k k k k k
gesic medication should be administered before the client's pain peaks (B).
k k k k k k k k k k
Providing comfort is a priority for the client who is dying, but sedation that impairsthe c
k k k k k k k k k k k k k k k k
lient's ability to interact and experience the time before life ends should be minimized
k k k k k k k k k k k k k k
(C). Offering a medication-free period allows the serum drug level to
k k k k k k k k k k
3k/k25
, fall, which is not an effective method to manage chronic pain (D).Correct A
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nswer: A k
4. When assessing a client with wrist restraints, the nurse observes that thefi
k k k k k k k k k k k k
ngers on the right hand are blue. What action should the nurse implementfirst
k k k k k k k k k k k k k
?
A. Loosen the right wrist restraint. k k k k
B. Apply a pulse oximeter to the right hand.
k k k k k k k
C. Compare hand color bilaterally. k k k
D. Palpate the right radial pulse.: The priority nursing action is to restore cir-
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kculation by loosening the restraint (A), because blue fingers (cyanosis) indicatesde
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creased circulation. (C and D) are also important nursing interventions, but do not
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have the priority of (A). Pulse oximetry (B) measures the saturation of hemoglobin
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with oxygen and is not indicated in situations where the cyanosis isrelated to mech
k k k k k k k k k k k k k k
anical compression (the restraints).
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Correct Answer: A k k
5. The nurse is assessing the nutritional status of several clients. Whichcl
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ient has the greatest nutritional need for additional intake of protein?
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A. A college-age track runner with a sprained ankle.
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4k/k25