ALL HESI Fundamentals Exam Test Bank updated
i i i i i i i
HESIiFundamentalsiExam,iAnswered
Anielderlyiclientiwithiaifracturedileftihipiisionistrictibedrest.iWhichinursingimeasureiisiessentiali
toitheiclient'sinursingicare?
A. Massageianyireddenediareasiforiatileastifiveiminutes.
B. Encourageiactiveirangeiofimotioniexercisesioniextremities.
C. Positionitheiclientilaterally,iprone,iandidorsallyiinisequence.
D. Gentlyiliftitheiclientiwhenimovingiintoiaidesirediposition.i-
Toiavoidishearingiforcesiwhenirepositioning,itheiclientishouldibeiliftedigentlyiacrossiaisurf
i
acei(D).iReddenediareasishouldinotibeimassagedi(A)isinceithisimayiincreaseitheidamageitoia
lreadyitraumatizediskin.iToicontrolipainiandimuscleispasms,iactiveirangeiofimotioni(B)ima
yibeilimitedionitheiaffectedileg.iTheipositionidescribediini(C)iisicontraindicatediforiaiclienti
withiaifracturedileftihip.
CorrectiAnswer:iD
Theinurseiisiadministeringimedicationsithroughiainasogastricitubei(NGT)iwhichiisiconnecte
ditoisuction.iAfteriensuringicorrectitubeiplacement,iwhatiactionishoulditheinurseitakeinext?
A. Clampitheitubeifori20iminutes.
B. Flushitheitubeiwithiwater.
,C. Administeritheimedicationsiasiprescribed.
D. Crushitheitabletsiandidissolveiinisterileiwater.i-
TheiNGTishouldibeiflushedibefore,iafteriandiinibetweenieachimedicationiadministeredi(B
i
).iOnceiallimedicationsiareiadministered,itheiNGTishouldibeiclampedifori20iminutesi(A).i(
CiandiD)imayibeiimplementedionlyiafteritheitubingihasibeeniflushed.
CorrectiAnswer:iB
Aiclientiwhoiisiinihospiceicareicomplainsiofiincreasingiamountsiofipain.iTheihealthcareiprov
ideriprescribesianianalgesicieveryifourihoursiasineeded.iWhichiactionishoulditheinurseiimpl
ement?
A. Giveianiaround-the-clockischeduleiforiadministrationiofianalgesics.
B. Administerianalgesicimedicationiasineedediwhenitheipainiisisevere.
C. Provideimedicationitoikeepitheiclientisedatediandiunawareiofistimuli.
D. Offeriaimedication-freeiperiodisoithatitheiclienticanidoidailyiactivities.i-
Theimostieffectiveimanagementiofipainiisiachievediusingianiaround-the-
i
clockischeduleithatiprovidesianalgesicimedicationsioniairegularibasisi(A)iandiiniaitimelyima
nner.iAnalgesicsiareilessieffectiveiifipainipersistsiuntiliitiisisevere,isoianianalgesicimedicatio
nishouldibeiadministeredibeforeitheiclient'sipainipeaksi(B).iProvidingicomfortiisiai priorityif
oritheiclientiwhoiisidying,ibutisedationithatiimpairsitheiclient'siabilityitoiinteractiandiexperie
nceitheitimeibeforeilifeiendsishouldibeiminimizedi(C).iOfferingiaimedication-
freeiperiodiallowsitheiserumidrugilevelitoifall,iwhichiisinotianieffectiveimethoditoimanageich
ronicipaini(D).
,CorrectiAnswer:iA
Wheniassessingiaiclientiwithiwristirestraints,itheinurseiobservesithatitheifingersionitheirightih
andiareiblue.iWhatiactionishoulditheinurseiimplementifirst?
A. Loosenitheirightiwristirestraint.
B. Applyiaipulseioximeteritoitheirightihand.
C. Compareihandicoloribilaterally.
D. Palpateitheirightiradialipulse.i-
Theipriorityinursingiactioniisitoirestoreicirculationibyilooseningitheirestrainti(A),ibecauseibl
i
ueifingersi(cyanosis)iindicatesidecreasedicirculation.i(CiandiD)iareialsoiimportantinursingii
nterventions,ibutidoinotihaveitheipriorityiofi(A).iPulseioximetryi(B)imeasuresitheisaturationi
ofihemoglobiniwithioxygeniandiisinotiindicatediinisituationsiwhereitheicyanosisiisirelateditoi
mechanicalicompressioni(theirestraints).
CorrectiAnswer:iA
Theinurseiisiassessingitheinutritionalistatusiofiseveraliclients.iWhichiclientihasitheigreatestin
utritionalineediforiadditionaliintakeiofiprotein?
A. Aicollege-ageitrackirunneriwithiaisprainediankle.
B. Ailactatingiwomaninursingiheri3-day-oldiinfant.
C. Aischool-agedichildiwithiTypei2idiabetes.
, D. Anielderlyimanibeingitreatediforiaipepticiulcer.i-
Ailactatingiwomani(B)ihasitheigreatestineediforiadditionaliproteiniintake.i(A,iC,iandiD)iare
i
alliconditionsithatirequireiprotein,ibutidoinotihaveitheiincreasedimetaboliciproteinidemand
i
siofilactation.
CorrectiAnswer:iB
Aiclientiisiinitheiradiologyidepartmentiati0900iwhenitheiprescriptionilevofloxacini(Levaqui
n)i500imgiIViq24hiisischeduleditoibeiadministered.iTheiclientireturnsitoitheiunitiati1300.iWh
atiisitheibestiinterventioniforitheinurseitoiimplement?
A. Contactitheihealthcareiprovideriandicompleteiaimedicationivarianceiform.
B. AdministeritheiLevaquiniati1300iandiresumeithei0900ischeduleiinitheimorning.
C. Notifyitheichargeinurseiandicompleteianiincidentireportitoiexplainitheimissedidose.
D. Giveitheimissedidoseiati1300iandichangeitheischeduleitoiadministeridailyiati1300.i-
Toiensureithatiaitherapeuticileveliofimedicationiisimaintained,itheinurseishouldiadministerit
i
heimissedidoseiasisooniasipossible,iandireviseitheiadministrationischeduleiaccordinglyitoipr
eventidangerouslyiincreasingitheileveliofitheimedicationiinitheibloodstreami(D).iTheinurseis
houldidocumentitheireasoniforitheilateidose,ibuti(AiandiC)iareinotiwarranted.i(B)icouldiresul
tiiniincreasedibloodilevelsiofitheidrug.
CorrectiAnswer:iD
Whileiinstructingiaimaleiclient'siwifeiinitheiperformanceiofipassiveirange-of-
motioniexercisesitoihisicontractedishoulder,itheinurseiobservesithatisheiisiholdingihisiarmia
boveiandibelowitheielbow.iWhatinursingiactionishoulditheinurseiimplement?
i i i i i i i
HESIiFundamentalsiExam,iAnswered
Anielderlyiclientiwithiaifracturedileftihipiisionistrictibedrest.iWhichinursingimeasureiisiessentiali
toitheiclient'sinursingicare?
A. Massageianyireddenediareasiforiatileastifiveiminutes.
B. Encourageiactiveirangeiofimotioniexercisesioniextremities.
C. Positionitheiclientilaterally,iprone,iandidorsallyiinisequence.
D. Gentlyiliftitheiclientiwhenimovingiintoiaidesirediposition.i-
Toiavoidishearingiforcesiwhenirepositioning,itheiclientishouldibeiliftedigentlyiacrossiaisurf
i
acei(D).iReddenediareasishouldinotibeimassagedi(A)isinceithisimayiincreaseitheidamageitoia
lreadyitraumatizediskin.iToicontrolipainiandimuscleispasms,iactiveirangeiofimotioni(B)ima
yibeilimitedionitheiaffectedileg.iTheipositionidescribediini(C)iisicontraindicatediforiaiclienti
withiaifracturedileftihip.
CorrectiAnswer:iD
Theinurseiisiadministeringimedicationsithroughiainasogastricitubei(NGT)iwhichiisiconnecte
ditoisuction.iAfteriensuringicorrectitubeiplacement,iwhatiactionishoulditheinurseitakeinext?
A. Clampitheitubeifori20iminutes.
B. Flushitheitubeiwithiwater.
,C. Administeritheimedicationsiasiprescribed.
D. Crushitheitabletsiandidissolveiinisterileiwater.i-
TheiNGTishouldibeiflushedibefore,iafteriandiinibetweenieachimedicationiadministeredi(B
i
).iOnceiallimedicationsiareiadministered,itheiNGTishouldibeiclampedifori20iminutesi(A).i(
CiandiD)imayibeiimplementedionlyiafteritheitubingihasibeeniflushed.
CorrectiAnswer:iB
Aiclientiwhoiisiinihospiceicareicomplainsiofiincreasingiamountsiofipain.iTheihealthcareiprov
ideriprescribesianianalgesicieveryifourihoursiasineeded.iWhichiactionishoulditheinurseiimpl
ement?
A. Giveianiaround-the-clockischeduleiforiadministrationiofianalgesics.
B. Administerianalgesicimedicationiasineedediwhenitheipainiisisevere.
C. Provideimedicationitoikeepitheiclientisedatediandiunawareiofistimuli.
D. Offeriaimedication-freeiperiodisoithatitheiclienticanidoidailyiactivities.i-
Theimostieffectiveimanagementiofipainiisiachievediusingianiaround-the-
i
clockischeduleithatiprovidesianalgesicimedicationsioniairegularibasisi(A)iandiiniaitimelyima
nner.iAnalgesicsiareilessieffectiveiifipainipersistsiuntiliitiisisevere,isoianianalgesicimedicatio
nishouldibeiadministeredibeforeitheiclient'sipainipeaksi(B).iProvidingicomfortiisiai priorityif
oritheiclientiwhoiisidying,ibutisedationithatiimpairsitheiclient'siabilityitoiinteractiandiexperie
nceitheitimeibeforeilifeiendsishouldibeiminimizedi(C).iOfferingiaimedication-
freeiperiodiallowsitheiserumidrugilevelitoifall,iwhichiisinotianieffectiveimethoditoimanageich
ronicipaini(D).
,CorrectiAnswer:iA
Wheniassessingiaiclientiwithiwristirestraints,itheinurseiobservesithatitheifingersionitheirightih
andiareiblue.iWhatiactionishoulditheinurseiimplementifirst?
A. Loosenitheirightiwristirestraint.
B. Applyiaipulseioximeteritoitheirightihand.
C. Compareihandicoloribilaterally.
D. Palpateitheirightiradialipulse.i-
Theipriorityinursingiactioniisitoirestoreicirculationibyilooseningitheirestrainti(A),ibecauseibl
i
ueifingersi(cyanosis)iindicatesidecreasedicirculation.i(CiandiD)iareialsoiimportantinursingii
nterventions,ibutidoinotihaveitheipriorityiofi(A).iPulseioximetryi(B)imeasuresitheisaturationi
ofihemoglobiniwithioxygeniandiisinotiindicatediinisituationsiwhereitheicyanosisiisirelateditoi
mechanicalicompressioni(theirestraints).
CorrectiAnswer:iA
Theinurseiisiassessingitheinutritionalistatusiofiseveraliclients.iWhichiclientihasitheigreatestin
utritionalineediforiadditionaliintakeiofiprotein?
A. Aicollege-ageitrackirunneriwithiaisprainediankle.
B. Ailactatingiwomaninursingiheri3-day-oldiinfant.
C. Aischool-agedichildiwithiTypei2idiabetes.
, D. Anielderlyimanibeingitreatediforiaipepticiulcer.i-
Ailactatingiwomani(B)ihasitheigreatestineediforiadditionaliproteiniintake.i(A,iC,iandiD)iare
i
alliconditionsithatirequireiprotein,ibutidoinotihaveitheiincreasedimetaboliciproteinidemand
i
siofilactation.
CorrectiAnswer:iB
Aiclientiisiinitheiradiologyidepartmentiati0900iwhenitheiprescriptionilevofloxacini(Levaqui
n)i500imgiIViq24hiisischeduleditoibeiadministered.iTheiclientireturnsitoitheiunitiati1300.iWh
atiisitheibestiinterventioniforitheinurseitoiimplement?
A. Contactitheihealthcareiprovideriandicompleteiaimedicationivarianceiform.
B. AdministeritheiLevaquiniati1300iandiresumeithei0900ischeduleiinitheimorning.
C. Notifyitheichargeinurseiandicompleteianiincidentireportitoiexplainitheimissedidose.
D. Giveitheimissedidoseiati1300iandichangeitheischeduleitoiadministeridailyiati1300.i-
Toiensureithatiaitherapeuticileveliofimedicationiisimaintained,itheinurseishouldiadministerit
i
heimissedidoseiasisooniasipossible,iandireviseitheiadministrationischeduleiaccordinglyitoipr
eventidangerouslyiincreasingitheileveliofitheimedicationiinitheibloodstreami(D).iTheinurseis
houldidocumentitheireasoniforitheilateidose,ibuti(AiandiC)iareinotiwarranted.i(B)icouldiresul
tiiniincreasedibloodilevelsiofitheidrug.
CorrectiAnswer:iD
Whileiinstructingiaimaleiclient'siwifeiinitheiperformanceiofipassiveirange-of-
motioniexercisesitoihisicontractedishoulder,itheinurseiobservesithatisheiisiholdingihisiarmia
boveiandibelowitheielbow.iWhatinursingiactionishoulditheinurseiimplement?
