PN FUNDAMENTALS HESI EXIT TEST BANK -
EXAMINATION COMPLETE QUESTIONS AND DETAILED
SOLUTIONS LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: The healthcare provider prescribes furosemide (Lasix)
15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters
should the nurse administer?
A. 1 ml.
B. 1.5 ml.
C. 1.75 ml.
D. 2 ml.
Answer:
(B) is the correct calculation: Dosage on hand/amount on hand = Dosage
desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5
ml.
Question 2: Correct Answer: B Heparin 20,000 units in 500 ml D5W
at 50 ml/hour has been infusing for 5½ hours. How much heparin
has the client received?
A. 11,000 units.
B. 13,000 units.
C. 15,000 units.
D. 17,000 units.
Answer:
(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of
units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units
in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2
hour amount of 1,000 to reach the same conclusion = 11,000 units.
,Question 3: Correct Answer: A The healthcare provider prescribes
morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml.
How many ml should the nurse administer?
A. 0.5 ml.
B. 1 ml.
C. 1.5 ml.
D. 2 ml.
Answer:
Using ratio and proportion:
Question 4: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be
infused over 8 hours. The infusion set delivers 10 drops per
milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute?
A. 80
B. 8
C. 21
D. 25
Answer:
The accepted formula for figuring drops per minute is: amount to be infused in
one hour × drop factor/time for infusion (min)= drops per minute. Using this
formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in
one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C).
Question 5: Correct Answer: C Which action is most important for
the nurse to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
, D. Put the glove on the dominant hand first.
Answer:
Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis (D).
Question 6: Correct Answer: C A client's infusion of normal saline
infiltrated earlier today, and approximately 500 ml of saline infused
into the subcutaneous tissue. The client is now complaining of
excruciating arm pain and demanding "stronger pain medications."
What initial action is most important for the nurse to take?
A. Ask about any past history of drug abuse or addiction.
B. Measure the pulse volume and capillary refill distal to the
infiltration.
C. Compress the infiltrated tissue to measure the degree of edema.
D. Evaluate the extent of ecchymosis over the forearm area.
Answer:
Pain and diminished pulse volume (B) are signs of compartment syndrome,
which can progress to complete loss of the peripheral pulse in the extremity.
Compartment syndrome occurs when external pressure (usually from a cast),
or internal pressure (usually from subcutaneous infused fluid), exceeds
capillary perfusion pressure resulting in decreased blood flow to the extremity.
(A) should not be pursued until physical causes of the pain are ruled out. (C)
is of less priority than determining the effects of the edema on circulation and
nerve function. Further assessment of the client's ecchymosis can be delayed
until the signs of edema and compression that suggest compartment
syndrome have been examined (D).
Question 7: Correct Answer: B An elderly male client who is
unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What
is the best client position for administration of the bolus tube
, feedings?
A. Prone.
B. Fowler's.
C. Sims'.
D. Supine.
Answer:
The client should be positioned in a semi-sitting (Fowler's) (B) position during
feeding to decrease the occurrence of aspiration. A gastrostomy tube, known
as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy
procedure, is inserted directly into the stomach through an incision in the
abdomen for long-term administration of nutrition and hydration in the
debilitated client. In (A and/or C), the client is placed on the abdomen, an
unsafe position for feeding. Placing the client in (D) increases the risk of
aspiration.
Question 8: Correct Answer: B A 73-year-old female client had a
hemiarthroplasty of the left hip yesterday due to a fracture resulting
from a fall. In reviewing hip precautions with the client, which
instruction should the nurse include in this client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach items on
the floor.
B. Place a pillow between your knees while lying in bed to prevent hip
dislocation.
C. It is safe to use a walker to get out of bed, but you need assistance
when walking.
D. Take pain medication 30 minutes after your physical therapy
sessions.
Answer:
EXAMINATION COMPLETE QUESTIONS AND DETAILED
SOLUTIONS LATEST UPDATE THIS YEAR JUST RELEASED
Question 1: The healthcare provider prescribes furosemide (Lasix)
15 mg IV stat. On hand is Lasix 20 mg/2 ml. How many milliliters
should the nurse administer?
A. 1 ml.
B. 1.5 ml.
C. 1.75 ml.
D. 2 ml.
Answer:
(B) is the correct calculation: Dosage on hand/amount on hand = Dosage
desired/x amount. 20 mg : 2 ml = 15 mg : x . 20x = 30. x = 30/20; = 1½ or 1.5
ml.
Question 2: Correct Answer: B Heparin 20,000 units in 500 ml D5W
at 50 ml/hour has been infusing for 5½ hours. How much heparin
has the client received?
A. 11,000 units.
B. 13,000 units.
C. 15,000 units.
D. 17,000 units.
Answer:
(A) is the correct calculation: 20,000 units/500 ml = 40 units (the amount of
units in one ml of fluid). 40 units/ml x 50 ml/hr = 2,000 units/hour (1,000 units
in 1/2 hour). 5.5 x 2,000 = 11,000 (A). OR, multiply 5 x 2,000 and add the 1/2
hour amount of 1,000 to reach the same conclusion = 11,000 units.
,Question 3: Correct Answer: A The healthcare provider prescribes
morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml.
How many ml should the nurse administer?
A. 0.5 ml.
B. 1 ml.
C. 1.5 ml.
D. 2 ml.
Answer:
Using ratio and proportion:
Question 4: 8mg: 1ml :: 4mg:Xml 8X=4 X=0.5 Correct Answer: A
The nurse prepares a 1,000 ml IV of 5% dextrose and water to be
infused over 8 hours. The infusion set delivers 10 drops per
milliliter. The nurse should regulate the IV to administer
approximately how many drops per minute?
A. 80
B. 8
C. 21
D. 25
Answer:
The accepted formula for figuring drops per minute is: amount to be infused in
one hour × drop factor/time for infusion (min)= drops per minute. Using this
formula: 1,000/8 hours = 125 ml/ hour 125 × 10 (drip factor) = 1,250 drops in
one hour. 1,250/ 60 (number of minutes in one hour) = 20.8 or 21 gtt/min (C).
Question 5: Correct Answer: C Which action is most important for
the nurse to implement when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
, D. Put the glove on the dominant hand first.
Answer:
Gloved hands held below waist level are considered unsterile (C). (A and B)
are not essential to maintaining asepsis. While it may be helpful to put the
glove on the dominant hand first, it is not necessary to ensure asepsis (D).
Question 6: Correct Answer: C A client's infusion of normal saline
infiltrated earlier today, and approximately 500 ml of saline infused
into the subcutaneous tissue. The client is now complaining of
excruciating arm pain and demanding "stronger pain medications."
What initial action is most important for the nurse to take?
A. Ask about any past history of drug abuse or addiction.
B. Measure the pulse volume and capillary refill distal to the
infiltration.
C. Compress the infiltrated tissue to measure the degree of edema.
D. Evaluate the extent of ecchymosis over the forearm area.
Answer:
Pain and diminished pulse volume (B) are signs of compartment syndrome,
which can progress to complete loss of the peripheral pulse in the extremity.
Compartment syndrome occurs when external pressure (usually from a cast),
or internal pressure (usually from subcutaneous infused fluid), exceeds
capillary perfusion pressure resulting in decreased blood flow to the extremity.
(A) should not be pursued until physical causes of the pain are ruled out. (C)
is of less priority than determining the effects of the edema on circulation and
nerve function. Further assessment of the client's ecchymosis can be delayed
until the signs of edema and compression that suggest compartment
syndrome have been examined (D).
Question 7: Correct Answer: B An elderly male client who is
unresponsive following a cerebral vascular accident (CVA) is
receiving bolus enteral feedings though a gastrostomy tube. What
is the best client position for administration of the bolus tube
, feedings?
A. Prone.
B. Fowler's.
C. Sims'.
D. Supine.
Answer:
The client should be positioned in a semi-sitting (Fowler's) (B) position during
feeding to decrease the occurrence of aspiration. A gastrostomy tube, known
as a PEG tube, due to placement by a percutaneous endoscopic gastrostomy
procedure, is inserted directly into the stomach through an incision in the
abdomen for long-term administration of nutrition and hydration in the
debilitated client. In (A and/or C), the client is placed on the abdomen, an
unsafe position for feeding. Placing the client in (D) increases the risk of
aspiration.
Question 8: Correct Answer: B A 73-year-old female client had a
hemiarthroplasty of the left hip yesterday due to a fracture resulting
from a fall. In reviewing hip precautions with the client, which
instruction should the nurse include in this client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach items on
the floor.
B. Place a pillow between your knees while lying in bed to prevent hip
dislocation.
C. It is safe to use a walker to get out of bed, but you need assistance
when walking.
D. Take pain medication 30 minutes after your physical therapy
sessions.
Answer:
