Hesi Fundamentals 2 Practice Exam Questions and Answers with Rationales

The nurse observes that a male client has removed the covering from an ice pack 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 - Answer: a. observe the appearance of the skin under the ice pack Rationale: the first action taken by the nurse should be to assess the skin for any possible thermal injury (a). If no injury to the skin has occurred, the nurse can take the other actions b,c,d as needed. The nurse mixes 50 mg of Nipride in 250mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60gtt/mL how many drops per minute should the client receive? a. 31 gtt/min b. 62 gtt/min c. 93 gtt/min d. 124 gtt/min - Answer: d. 124 gtt/min Rationale: d is the correct calculation:182/2.2 = 82.73 kg 5mcg x 82.73 = 413.65 mcg/min. 250/50,000mcg = 200 mcg/ml 413.65/200 = 2.07 mL 60 x 2.07 = 124.28 gtt/min The healthcare provider prescribes an IV infusion of 1,000mL Ringer's Lactate with 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by caesarean 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? a. 42 gtt/min b. 83 gtt/min c. 125 gtt/min d. 250 gtt/min - Answer: b. 83 gtt/min Rationale: 1000ml / 4 hours = 250 ml/hour 250ml/60 min = 4.1667ml/min 4.1667ml/min x 20 gtt/ml = 83.33 gtt/min Which assessment data provides the most accurate determination of proper placement of a nasogastric tube? a. aspirating gastric contents to assure a pH value of 4 or less b. hearing air pass in the stomach after injecting air into the tubingc. examining a chest x-ray obtained after the tubing was inserted d. checking the remaining length of tubing to ensure that the correct length was inserted - Answer: c. examining a chest x-ray obtained after tubing was inserted Rationale: both a and b are methods used to determine proper placement of NG tubing. However, the best indicator is c. D is not an indicator of proper placement Three days following 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 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 Rationale: postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when the 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 NG tube the last 2 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 Rationale: the immediate priority is to determine if the tube is functioning properly, which could 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 were successful, the client may require an antiemetic (d). A hospitalized male patient is receiving nasogastric 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 now feels fine. What action is the 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 HCP c. after clearing the tube with 30mL 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. stop the feeding, explain to the family why it is being stopped, and notify HCPRationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding tube upward into the esophagus, placing the client at increased risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive method for these tubes, and the nurse should assess tube placement in this way prior to taking any further action (c). (a) and (b) are not indicated. The auscultating method (d) has been found to be unreliable for smallbore feeding tubes. 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. demonstrate loss of remote memory b. exhibits expressive dysphagia c. has a diminished attention span d. is disoriented to place and time - Answer: d. is disoriented to place and time Rationale: 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 a diminished attention span (c).