Fundamental HESI, Hesi Fundamentals, Hesi Fundamentals
Practice Test, UNIT 1: Foundations of Nursing Practice
A nurse is obtaining a health history from the newly admitted client who has chronic pain
in the knee. What should the nurse include in the pain assessment? Select all that apply.
1 Pain history, including location, intensity, and quality of pain
2 Client's purposeful body movement in arranging the papers on the bedside table
3 Pain pattern, including precipitating and alleviating factors
4 Vital signs such as increased blood pressure and heart rate
5 The client's family statement about increases in pain with ambulation
: 1,3
Accurate pain assessment includes pain history with the client's identification of pain
location, intensity, and quality and helps the nurse to identify what pain means to the
client. The pattern of pain includes time of onset, duration, and recurrence of pain and its
assessment helps the nurse anticipate and meet the needs of the client. Assessment of
the precipitating factors helps the nurse prevent the pain and determine it cause.
Purposeless movements such as tossing and turning or involuntary movements such as a
reflexive jerking may indicate pain. Physiological responses such as elevated blood
pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is
a subjective experience and therefore the nurse has to ask the client directly instead of
accepting statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?
1 Immediately stop the infusion.
2 Lower the height of the enema bag.
3 Advance the enema tubing 2 to 3 inches.
4 Clamp the tube for 2 minutes, then restart the infusion.
:2
,Abdominal cramping during a soapsuds enema may be due to too rapid administration of
the enema solution. Lowering the height of the enema bag slows the flow and allows the
bowel time to adapt to the distention without causing excessive discomfort. Stopping the
infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the
tube for several minutes then restarting the infusion may be attempted if slowing the
infusion does not relieve the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a
nurse observes that the client's skin is dry and scaly. The nurse applies emollients and
reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
1 The nurse also should have instituted a plan to increase activity.
2 The nurse provided supportive nursing care for the well-being of the client.
3 Debridement of the pressure ulcer should have been done before the dressing was
applied.
4 Treatment should not have been instituted until the health care provider's prescriptions
were received.
:2
According to the Nurse Practice Act, a nurse may independently treat human responses
to actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing was
applied. Application of an emollient and reinforcing a dressing are independent nursing
functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had
a fight and that the client is now lying unconscious on the floor. What is the most
important action the nurse needs to take?
1 Ask the client if he is okay.
2 Call security from the room.
3 Find out if there is anyone else in the room.
4 Ask security to make sure the room is safe
,:4
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if
the client is okay and make sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
1. 4 to 8 hours
2. 12 to 24 hours
3. 24 to 48 hours
4. 72 to 96 hours: 4
Best practice guidelines recommend replacing administration sets no more frequently
than 72 to 96 hours after initiation of use in patients not receiving blood, blood products,
or fat emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
A nurse is taking care of a client who has severe back pain as a result of a work injury.
What nursing considerations should be made when determining the client's plan of care?
Select all that apply.
1. Ask the client what is the client's acceptable level of pain.
2. Eliminate all activities that precipitate the pain. 3
Administer the pain medications regularly around the clock.
4 . Use a different pain scale each time to promote patient education.
5. Assess the client's pain every 15 minutes: 1,3
The nurse works together with the client in order to determine the tolerable level of pain.
Considering that the client has chronic, not acute pain, the goal of the pain management
is to decrease pain to the tolerable level instead of eliminating pain completely.
Administration of pain medications around the clock will provide the stable level of pain
medication in the blood and relieve the pain. Elimination of all activities that precipitate
the client's pain is not possible even though the nurse will try to minimize such activities.
The same pain scale should be used for assessment of the client's pain level helps to
, ensure consistency and accuracy in the pain assessment. Only management of acute pain
such as postoperative pain requires the pain assessment at frequent intervals.
Which assessment data would provide 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 tubing.
C) 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.
: C) Examining a chest x-ray obtained after the tubing was inserted
Both (A and B) are methods used to determine proper placement of the NG tubing.
However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator
of proper placement
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
A) Arms.
B) Upper torso.
C) Head.
D) Feet
: B) Upper torso
The center of gravity for adults is the hips. However, as the person grows older, a stooped
posture is common because of the changes from osteoporosis and normal bone
degeneration, and the knees, hips, and elbows flex. This stooped posture results in the
Practice Test, UNIT 1: Foundations of Nursing Practice
A nurse is obtaining a health history from the newly admitted client who has chronic pain
in the knee. What should the nurse include in the pain assessment? Select all that apply.
1 Pain history, including location, intensity, and quality of pain
2 Client's purposeful body movement in arranging the papers on the bedside table
3 Pain pattern, including precipitating and alleviating factors
4 Vital signs such as increased blood pressure and heart rate
5 The client's family statement about increases in pain with ambulation
: 1,3
Accurate pain assessment includes pain history with the client's identification of pain
location, intensity, and quality and helps the nurse to identify what pain means to the
client. The pattern of pain includes time of onset, duration, and recurrence of pain and its
assessment helps the nurse anticipate and meet the needs of the client. Assessment of
the precipitating factors helps the nurse prevent the pain and determine it cause.
Purposeless movements such as tossing and turning or involuntary movements such as a
reflexive jerking may indicate pain. Physiological responses such as elevated blood
pressure and heart rate are most likely to be absent in the client with chronic pain. Pain is
a subjective experience and therefore the nurse has to ask the client directly instead of
accepting statement of the family members.
While undergoing a soapsuds enema, the client reports abdominal cramping. What action
should the nurse take?
1 Immediately stop the infusion.
2 Lower the height of the enema bag.
3 Advance the enema tubing 2 to 3 inches.
4 Clamp the tube for 2 minutes, then restart the infusion.
:2
,Abdominal cramping during a soapsuds enema may be due to too rapid administration of
the enema solution. Lowering the height of the enema bag slows the flow and allows the
bowel time to adapt to the distention without causing excessive discomfort. Stopping the
infusion is not necessary. Advancing the enema tubing is not appropriate. Clamping the
tube for several minutes then restarting the infusion may be attempted if slowing the
infusion does not relieve the cramps.
During the initial physical assessment of a newly admitted client with a pressure ulcer, a
nurse observes that the client's skin is dry and scaly. The nurse applies emollients and
reinforces the dressing on the pressure ulcer. Legally, were the nurse's actions adequate?
1 The nurse also should have instituted a plan to increase activity.
2 The nurse provided supportive nursing care for the well-being of the client.
3 Debridement of the pressure ulcer should have been done before the dressing was
applied.
4 Treatment should not have been instituted until the health care provider's prescriptions
were received.
:2
According to the Nurse Practice Act, a nurse may independently treat human responses
to actual or potential health problems. An activity level is prescribed by a health care
provider; this is a dependent function of the nurse. There is not enough information to
come to the conclusion that debridement should have been done before the dressing was
applied. Application of an emollient and reinforcing a dressing are independent nursing
functions.
A visitor comes to the nursing station and tells the nurse that a client and his relative had
a fight and that the client is now lying unconscious on the floor. What is the most
important action the nurse needs to take?
1 Ask the client if he is okay.
2 Call security from the room.
3 Find out if there is anyone else in the room.
4 Ask security to make sure the room is safe
,:4
Safety is the first priority when responding to a presumably violent situation. The nurse
needs to have security enter the room to ensure it is safe. Then it can be determined if
the client is okay and make sure that any other people in the room are safe
To ensure the safety of a client who is receiving a continuous intravenous normal saline
infusion, the nurse should change the administration set every:
1. 4 to 8 hours
2. 12 to 24 hours
3. 24 to 48 hours
4. 72 to 96 hours: 4
Best practice guidelines recommend replacing administration sets no more frequently
than 72 to 96 hours after initiation of use in patients not receiving blood, blood products,
or fat emulsions. This evidence-based practice is safe and cost effective. Changing the
administration set every 4 to 48 hours is not a cost-effective practice
A nurse is taking care of a client who has severe back pain as a result of a work injury.
What nursing considerations should be made when determining the client's plan of care?
Select all that apply.
1. Ask the client what is the client's acceptable level of pain.
2. Eliminate all activities that precipitate the pain. 3
Administer the pain medications regularly around the clock.
4 . Use a different pain scale each time to promote patient education.
5. Assess the client's pain every 15 minutes: 1,3
The nurse works together with the client in order to determine the tolerable level of pain.
Considering that the client has chronic, not acute pain, the goal of the pain management
is to decrease pain to the tolerable level instead of eliminating pain completely.
Administration of pain medications around the clock will provide the stable level of pain
medication in the blood and relieve the pain. Elimination of all activities that precipitate
the client's pain is not possible even though the nurse will try to minimize such activities.
The same pain scale should be used for assessment of the client's pain level helps to
, ensure consistency and accuracy in the pain assessment. Only management of acute pain
such as postoperative pain requires the pain assessment at frequent intervals.
Which assessment data would provide 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 tubing.
C) 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.
: C) Examining a chest x-ray obtained after the tubing was inserted
Both (A and B) are methods used to determine proper placement of the NG tubing.
However, the best indicator that the tubing is properly placed is (C). (D) is not an indicator
of proper placement
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
A) Arms.
B) Upper torso.
C) Head.
D) Feet
: B) Upper torso
The center of gravity for adults is the hips. However, as the person grows older, a stooped
posture is common because of the changes from osteoporosis and normal bone
degeneration, and the knees, hips, and elbows flex. This stooped posture results in the
