HESI FUNDAMENTAL UPDATED ACTUAL
QUESTIONS AND CORRECT ANSWERS
◉ 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?
Answer: 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?
Answer: 83 gtt/min
◉ Which assessment data provides the most accurate
determination of proper placement of a nasogastric tube?
Answer: 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.
Answer: 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.
,Answer: 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.
Answer: 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
Answer: 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.
Answer: 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--
QUESTIONS AND CORRECT ANSWERS
◉ 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?
Answer: 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?
Answer: 83 gtt/min
◉ Which assessment data provides the most accurate
determination of proper placement of a nasogastric tube?
Answer: 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.
Answer: 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.
,Answer: 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.
Answer: 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
Answer: 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.
Answer: 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--
