HESI RN Fundamentals
1. The nurse observes a newly admitted older adult female take short steps and walk very
slowly while pushing a walker in front of her. What action should the nurse take in
response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
2. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain.
The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse
administer?
(Round to the nearest tenth.)
1.5mg
3. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation
remains at 94%, which is the same reading obtained prior to starting the procedure. What action
should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
,D) Apply an oxygen mask over the client’s nose and mouth.
4. An older woman with end stage heart disease is hospitalized for severe heart failure. She is
alert, oriented, and requests that no heroic measures are implemented if her breathing stops.
What action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a “do not resuscitate” (DNR) prescription.
C) Set up a family conference to discuss the client’s.
D) Consult the palliative care team about client’s care.
5. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye
drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this
client’s teaching?
A) “Do not allow the dropper bottle to touch the eye.”
B) “Administer the medication directly on the cornea.”
C) “Squeeze your eye closed after administering the drops.”
D) “Wash your hands after each administration of eye drops.”
6. When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
, 7. The home health nurse is reviewing the personal care of an elderly client who lives alone.
Which client assessment findings indicate the need to assign an unlicensed assistive personnel?
(UAP) to provide routine foot care and file the client’s toenails? Select all that apply.)
A) syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
8. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client’s risk for infection related to
the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
9. To assess the quality of an adult client’s pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
1. The nurse observes a newly admitted older adult female take short steps and walk very
slowly while pushing a walker in front of her. What action should the nurse take in
response to these observations?
A) Complete a full fall risk assessment of the client.
B) Teach the client to take longer steps at faster pace.
C) Suggest that the the client use a wheelchair instead of a walker.
D) Place client on bedrest until the healthcare provider is notified.
2. A client is receiving ketorolac (Toradol) IM 45 mg IM 6 hours for postoperative pain.
The available 2 ml vial is labeled , Toradol IM 30 mg/ml, How many should the nurse
administer?
(Round to the nearest tenth.)
1.5mg
3. While suctioning a client’s nasopharynx, the nurse observes that the client’s oxygen saturation
remains at 94%, which is the same reading obtained prior to starting the procedure. What action
should the nurse take in response to this finding?
A) Reposition the pulse oximeter clip to obtain a new reading.
B) Stop suctioning until the pulse oximeter reading is above 95%.
C) Complete the intermittent suction of the nasopharynx.
,D) Apply an oxygen mask over the client’s nose and mouth.
4. An older woman with end stage heart disease is hospitalized for severe heart failure. She is
alert, oriented, and requests that no heroic measures are implemented if her breathing stops.
What action should the nurse take first?
A) Discuss with the client her meaning of heroic measures.
B) Obtain a “do not resuscitate” (DNR) prescription.
C) Set up a family conference to discuss the client’s.
D) Consult the palliative care team about client’s care.
5. A client diagnosed with primary open-angle glaucoma received a prescription for biotic eye
drops, pilocarpine HCl (Pilocarpine). What instruction should the nurse plan to include in this
client’s teaching?
A) “Do not allow the dropper bottle to touch the eye.”
B) “Administer the medication directly on the cornea.”
C) “Squeeze your eye closed after administering the drops.”
D) “Wash your hands after each administration of eye drops.”
6. When assessing a client who starts to wheeze related data should obtain?
A) Presence of radiation.
B) Heart sounds.
C) Body temperature.
D) Precipitating factors.
, 7. The home health nurse is reviewing the personal care of an elderly client who lives alone.
Which client assessment findings indicate the need to assign an unlicensed assistive personnel?
(UAP) to provide routine foot care and file the client’s toenails? Select all that apply.)
A) syncope when bending.
B) Hand tremors.
C) Diminished visual acuity.
D) Urinary incontinence.
E) Shuffling gait.
8. A client is discharged to a long-term care facility with an indwelling urinary catheter. Which
nursing action should be included in the plan to reduce the client’s risk for infection related to
the catheter?
A) Flush the catheter daily with sterile saline.
B) Encourage increased intake of oral fluids.
C) Administer a PRN antipyretic if a fever develops.
D) Secure the drainage bag at bladder level during transport.
9. To assess the quality of an adult client’s pain, what approach should the nurse use?
A) Observe body language and movement.
B) Provide a numeric pain scale.
C) Ask the client to describe the pain.
D) Identify effective pain relief measures.
