NAXLEX FUNDAMENTAL HESI 5
Question 1: ESHELIET Report Wrong Answer Explanation
Correct Answer: D
The nurse is teaching a client how to self-administer low-
molecular-weight heparin subcutaneously. Which instruction
Reason: Massaging the injection site can cause bruising
should the nurse include?
and bleeding, and is not recommended for
A. Massage the injection site to increase absorption. X subcutaneous heparin injections.
B. Rotate injections between the abdomen and gluteal areas. X Reason: Rotating injections between different body sites
C. Expel the air in the prefilled syringe prior to injection. X can increase the risk of hematoma formation and skin
irritation, and is not advised for subcutaneous heparin
D. Inject in abdominal area at least 2 inches from the umbilicus. v/
injections.
Reason: Expelling the air in the prefilled syringe can
result in a loss of medication dose, and is not necessary
for subcutaneous heparin injections.
Reason: Injecting in the abdominal area at least 2 inches
from the umbilicus is the correct technique for
subcutaneous heparin injections, as it reduces the risk of
injury to blood vessels and nerves, and ensures
consistent absorption of the medication.
Question 2: BTG ELIESI Report Wrong Answer Explanation
Correct Answer: A,D,E
Patient Data
Choice A: Lead the client in guided imagery
Exhibits
Based on the trending heart rate and pain score, what should
This is a correct choice because guided imagery is a
the nurse do? Select all that apply.
non-pharmacological intervention that can help reduce
pain and anxiety by creating a relaxing mental image for
History and Physical Nurses Notes Orders
the client. Guided imagery can also lower the heart rate
The client is a 56-year old woman who had an anteroposterior spinal and blood pressure by activating the parasympathetic
fusion 2 days ago. She tolerated the procedure well and has been nervous system.
progressively increasing her walking distance.
Choice B: Give a dose of 2.5 mg of Morphine
A. Lead the client in guided imagery
This is an incorrect choice because morphine is an
B. Give a dose of 2.5 mg of Morphine
opioid analgesic that can cause respiratory depression,
C. Assist the client to walk around the room
hypotension, and bradycardia. The client's heart rate is
D. Assess for sources of pain other than the surgical site
already elevated, which could indicate inadequate pain
E. Consult with the surgeon about the pain level relief or anxiety. Giving more morphine could worsen the
client's condition and mask the underlying cause of the
Hide Correct Answer and Explanation pain.
Choice C: Assist the client to walk around the room
This is an incorrect choice because walking around the
room could increase the client's pain and heart rate by
stimulating the sympathetic nervous system. The client
has already done ambulation exercises with physical
therapy at 1200, so there is no need to repeat them at
1400. The client should be allowed to rest in bed and
conserve energy.
, Choice D: Assess for sources of pain other than the
surgical site
This is a correct choice because the nurse should
always assess the client holistically and rule out any
other potential causes of pain, such as infection,
inflammation, or ischemia. The nurse should also check
the surgical site for any signs of bleeding, hematoma, or
infection. The nurse should use a comprehensive pain
assessment tool that includes the location, intensity,
quality, duration, frequency, and aggravating and
relieving factors of the pain.
Choice E: Consult with the surgeon about the pain level
This is a correct choice because the nurse should
collaborate with the surgeon and other members of the
health care team to provide optimal pain management
for the client. The nurse should report the client's pain
score, vital signs, medication administration, and
response to interventions. The surgeon may order
additional tests or medications to address the cause of
the pain and improve the client's comfort.
Question 3: ELELUELIEST Report Wrong Answer Explanation
Correct Answer: D
The nurse is caring for a client who is postoperative and
receiving supplemental oxygen at 2 L/minute via nasal cannula. Switching to a non-rebreather mask is not the immediate
The oxygen saturation is 89%. Which action should the nurse
action to take. Non-rebreather masks deliver a high
implement?
concentration of oxygen, typically reserved for severe
hypoxia. The patient’'s oxygen saturation is low, but not
A. Switch to a non-rebreather mask. X
critically low. It's important to first ensure the accuracy of
B. Remove the nasal cannula. X
the reading before escalating oxygen delivery methods.
C. Increase the oxygen to 3 L/minute. X
Removing the nasal cannula is not advisable. The
D. Verify the placement of the pulse oximeter. v/
patient is postoperative and may have impaired gas
exchange due to anesthesia, pain, or decreased mobility.
Hide Correct Answer and Explanation Removing the supplemental oxygen may worsen the
patient’s hypoxemia and increase the risk of
complications.
Increasing the oxygen to 3 L/minute could be a potential
action if the oxygen saturation reading is accurate and
the patient’s condition does not improve. However, any
changes to a patient’s oxygen therapy should be made
under the guidance of a healthcare provider. It's
important to first verify the accuracy of the oxygen
saturation reading.
Verifying the placement of the pulse oximeter is the
highest priority action. Before making changes to the
oxygen flow rate, it's important to ensure that the oxygen
saturation reading is accurate. Incorrect placement or
function of the pulse oximeter could lead to inaccurate
readings.
, Question 4: EELELIEST Report Wrong Answer Explanation
Correct Answer: C
Which assessment is most important for the nurse to perform
prior to the application of a heating pad?
Limitations to range of motion are not directly related to
the application of a heating pad. A heating pad may help
A. Limitations to range of motion. X
reduce pain and stiffness, but it does not affect the range
B. Muscle strength and tone. X
of motion itself.
C. Degree of neurosensory impairment. v/
Muscle strength and tone are also not directly related to
D. Presence of rebound phenomenon. X
the application of a heating pad. A heating pad may relax
tense muscles, but it does not affect the strength or tone
Hide Correct Answer and Explanation of the muscles.
Degree of neurosensory impairment is the most
important assessment for the nurse to perform prior to
the application of a heating pad. A heating pad can
cause burns or tissue damage if the patient has impaired
sensation and cannot feel the heat or pain. The nurse
should check the patient's ability to perceive
temperature, pressure, and pain before applying a
heating pad.
Presence of rebound phenomenon is not relevant to the
application of a heating pad. Rebound phenomenon
refers to the worsening of symptoms after discontinuing
a medication or treatment. A heating pad does not cause
rebound phenomenon.
Question 5: LG ELIEIT Report Wrong Answer Explanation
Correct Answer: A
After an intravenous antibiotic is started, the nurse determines
that the medication is not prescribed for the client and stops the Notify the healthcare provider is the correct action
infusion. Which action should the nurse implement next?
because it is the nurse's responsibility to report any
medication errors or adverse reactions to the prescriber
A. Notify the healthcare provider. v/
as soon as possible.
B. Document the event on the chart. X
C. Complete an incident report. X Document the event on the chart is not the next action
D. Inform the nurse on the next shift. X because it should be done after notifying the healthcare
provider and completing an incident report.
Hide Correct Answer and Explanation Complete an incident report is not the next action
because it should be done after notifying the healthcare
provider and before documenting the event on the chart.
Inform the nurse on the next shift is not the next action
because it should be done after documenting the event
on the chart and during handoff.
Question 1: ESHELIET Report Wrong Answer Explanation
Correct Answer: D
The nurse is teaching a client how to self-administer low-
molecular-weight heparin subcutaneously. Which instruction
Reason: Massaging the injection site can cause bruising
should the nurse include?
and bleeding, and is not recommended for
A. Massage the injection site to increase absorption. X subcutaneous heparin injections.
B. Rotate injections between the abdomen and gluteal areas. X Reason: Rotating injections between different body sites
C. Expel the air in the prefilled syringe prior to injection. X can increase the risk of hematoma formation and skin
irritation, and is not advised for subcutaneous heparin
D. Inject in abdominal area at least 2 inches from the umbilicus. v/
injections.
Reason: Expelling the air in the prefilled syringe can
result in a loss of medication dose, and is not necessary
for subcutaneous heparin injections.
Reason: Injecting in the abdominal area at least 2 inches
from the umbilicus is the correct technique for
subcutaneous heparin injections, as it reduces the risk of
injury to blood vessels and nerves, and ensures
consistent absorption of the medication.
Question 2: BTG ELIESI Report Wrong Answer Explanation
Correct Answer: A,D,E
Patient Data
Choice A: Lead the client in guided imagery
Exhibits
Based on the trending heart rate and pain score, what should
This is a correct choice because guided imagery is a
the nurse do? Select all that apply.
non-pharmacological intervention that can help reduce
pain and anxiety by creating a relaxing mental image for
History and Physical Nurses Notes Orders
the client. Guided imagery can also lower the heart rate
The client is a 56-year old woman who had an anteroposterior spinal and blood pressure by activating the parasympathetic
fusion 2 days ago. She tolerated the procedure well and has been nervous system.
progressively increasing her walking distance.
Choice B: Give a dose of 2.5 mg of Morphine
A. Lead the client in guided imagery
This is an incorrect choice because morphine is an
B. Give a dose of 2.5 mg of Morphine
opioid analgesic that can cause respiratory depression,
C. Assist the client to walk around the room
hypotension, and bradycardia. The client's heart rate is
D. Assess for sources of pain other than the surgical site
already elevated, which could indicate inadequate pain
E. Consult with the surgeon about the pain level relief or anxiety. Giving more morphine could worsen the
client's condition and mask the underlying cause of the
Hide Correct Answer and Explanation pain.
Choice C: Assist the client to walk around the room
This is an incorrect choice because walking around the
room could increase the client's pain and heart rate by
stimulating the sympathetic nervous system. The client
has already done ambulation exercises with physical
therapy at 1200, so there is no need to repeat them at
1400. The client should be allowed to rest in bed and
conserve energy.
, Choice D: Assess for sources of pain other than the
surgical site
This is a correct choice because the nurse should
always assess the client holistically and rule out any
other potential causes of pain, such as infection,
inflammation, or ischemia. The nurse should also check
the surgical site for any signs of bleeding, hematoma, or
infection. The nurse should use a comprehensive pain
assessment tool that includes the location, intensity,
quality, duration, frequency, and aggravating and
relieving factors of the pain.
Choice E: Consult with the surgeon about the pain level
This is a correct choice because the nurse should
collaborate with the surgeon and other members of the
health care team to provide optimal pain management
for the client. The nurse should report the client's pain
score, vital signs, medication administration, and
response to interventions. The surgeon may order
additional tests or medications to address the cause of
the pain and improve the client's comfort.
Question 3: ELELUELIEST Report Wrong Answer Explanation
Correct Answer: D
The nurse is caring for a client who is postoperative and
receiving supplemental oxygen at 2 L/minute via nasal cannula. Switching to a non-rebreather mask is not the immediate
The oxygen saturation is 89%. Which action should the nurse
action to take. Non-rebreather masks deliver a high
implement?
concentration of oxygen, typically reserved for severe
hypoxia. The patient’'s oxygen saturation is low, but not
A. Switch to a non-rebreather mask. X
critically low. It's important to first ensure the accuracy of
B. Remove the nasal cannula. X
the reading before escalating oxygen delivery methods.
C. Increase the oxygen to 3 L/minute. X
Removing the nasal cannula is not advisable. The
D. Verify the placement of the pulse oximeter. v/
patient is postoperative and may have impaired gas
exchange due to anesthesia, pain, or decreased mobility.
Hide Correct Answer and Explanation Removing the supplemental oxygen may worsen the
patient’s hypoxemia and increase the risk of
complications.
Increasing the oxygen to 3 L/minute could be a potential
action if the oxygen saturation reading is accurate and
the patient’s condition does not improve. However, any
changes to a patient’s oxygen therapy should be made
under the guidance of a healthcare provider. It's
important to first verify the accuracy of the oxygen
saturation reading.
Verifying the placement of the pulse oximeter is the
highest priority action. Before making changes to the
oxygen flow rate, it's important to ensure that the oxygen
saturation reading is accurate. Incorrect placement or
function of the pulse oximeter could lead to inaccurate
readings.
, Question 4: EELELIEST Report Wrong Answer Explanation
Correct Answer: C
Which assessment is most important for the nurse to perform
prior to the application of a heating pad?
Limitations to range of motion are not directly related to
the application of a heating pad. A heating pad may help
A. Limitations to range of motion. X
reduce pain and stiffness, but it does not affect the range
B. Muscle strength and tone. X
of motion itself.
C. Degree of neurosensory impairment. v/
Muscle strength and tone are also not directly related to
D. Presence of rebound phenomenon. X
the application of a heating pad. A heating pad may relax
tense muscles, but it does not affect the strength or tone
Hide Correct Answer and Explanation of the muscles.
Degree of neurosensory impairment is the most
important assessment for the nurse to perform prior to
the application of a heating pad. A heating pad can
cause burns or tissue damage if the patient has impaired
sensation and cannot feel the heat or pain. The nurse
should check the patient's ability to perceive
temperature, pressure, and pain before applying a
heating pad.
Presence of rebound phenomenon is not relevant to the
application of a heating pad. Rebound phenomenon
refers to the worsening of symptoms after discontinuing
a medication or treatment. A heating pad does not cause
rebound phenomenon.
Question 5: LG ELIEIT Report Wrong Answer Explanation
Correct Answer: A
After an intravenous antibiotic is started, the nurse determines
that the medication is not prescribed for the client and stops the Notify the healthcare provider is the correct action
infusion. Which action should the nurse implement next?
because it is the nurse's responsibility to report any
medication errors or adverse reactions to the prescriber
A. Notify the healthcare provider. v/
as soon as possible.
B. Document the event on the chart. X
C. Complete an incident report. X Document the event on the chart is not the next action
D. Inform the nurse on the next shift. X because it should be done after notifying the healthcare
provider and completing an incident report.
Hide Correct Answer and Explanation Complete an incident report is not the next action
because it should be done after notifying the healthcare
provider and before documenting the event on the chart.
Inform the nurse on the next shift is not the next action
because it should be done after documenting the event
on the chart and during handoff.
