HESI FUNDAMENTALS PRACTICE EXAM UPDATED WITH
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES
The nurse observes that a male client has removed the covering from an ice park
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.
Observe the appearance of the skin under the ice pack (The first action taken by the
nurse should be to assess the skin for any possible thermal injury. If no injury to
the skin has occurred, the nurse can take the other actions.)
An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the
best client position for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sim's
D. Supine
B. Fowler's
(The client should be positioned in a semi-setting (B) position during feeding to
decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to
placement by a percutaneous endoscopic gastronomy procedure, is inserted
directly into the stomach through an incision in the abdomen for long-term
administration of nutrition and hydration in the debilitated client. In (A and/or C),
the client is placed on the abdomen, an unsafe position for feeding. Placing the
client in (D) increases the risk
The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor
of 60 gtt/mL, how many drops per minute should the client receive?
124 gtt/min
A hospitalized male client is receiving nasogastric tube 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 feels fine now. What action is 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 the
HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from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.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
the tube.
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. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time
D. is disoriented to place and time (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 diminished attention span. (C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his
breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD.
A. Commend the client for selecting a high biologic value protein. (Foods such as
eggs and milk (A) are high biologic proteins which are allowed because they are
complete proteins and supply the essential amino acids that are necessary for
growth and cell repair. Orange juice is rich in potassium and should not be
encouraged. The client has made a good diet choice so (D) is not necessary.)
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—
, 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 upper torso becoming the center of gravity for
older persons.)
In developing a plan of care for a client with dementia, the nurse should remember
that confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep
B. often follows relocation to new surroundings (Relocation (B) often results in
confusion among elderly clients-- moving is stressful for anyone. (A) is
stereotypical judgement. Stress in the elderly often manifests itself as confusion, so
(C) is wrong. Adequate sleep is not a prevention (D) for confusion.)
A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care
C. demonstrates the wound care procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the
client's ability to perform a task, while (A and B) are subjective measures. (D) is
important, but is less of a priority than the nurse's assessment of the client's ability
to complete wound care.)
A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the
preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?"
QUESTIONS AND CORRECT ANSWERS WITH DETAILED
RATIONALES
The nurse observes that a male client has removed the covering from an ice park
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.
Observe the appearance of the skin under the ice pack (The first action taken by the
nurse should be to assess the skin for any possible thermal injury. If no injury to
the skin has occurred, the nurse can take the other actions.)
An elderly male client who is unresponsive following a cerebral vascular accident
(CVA) is receiving bolus enteral feedings through a gastronomy tube. What is the
best client position for administration of the bolus tube feedings?
A. Prone
B. Fowler's
C. Sim's
D. Supine
B. Fowler's
(The client should be positioned in a semi-setting (B) position during feeding to
decrease occurrence of aspiration. A gastronomy tube, known as PEG tube, due to
placement by a percutaneous endoscopic gastronomy procedure, is inserted
directly into the stomach through an incision in the abdomen for long-term
administration of nutrition and hydration in the debilitated client. In (A and/or C),
the client is placed on the abdomen, an unsafe position for feeding. Placing the
client in (D) increases the risk
The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor
of 60 gtt/mL, how many drops per minute should the client receive?
124 gtt/min
A hospitalized male client is receiving nasogastric tube 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 feels fine now. What action is 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 the
HCP.
C. After clearing the tube with 30 ml 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.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
the tube.
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. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time
D. is disoriented to place and time (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 diminished attention span. (C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his
breakfast. What action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD.
A. Commend the client for selecting a high biologic value protein. (Foods such as
eggs and milk (A) are high biologic proteins which are allowed because they are
complete proteins and supply the essential amino acids that are necessary for
growth and cell repair. Orange juice is rich in potassium and should not be
encouraged. The client has made a good diet choice so (D) is not necessary.)
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—
, 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 upper torso becoming the center of gravity for
older persons.)
In developing a plan of care for a client with dementia, the nurse should remember
that confusion in the elderly
A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep
B. often follows relocation to new surroundings (Relocation (B) often results in
confusion among elderly clients-- moving is stressful for anyone. (A) is
stereotypical judgement. Stress in the elderly often manifests itself as confusion, so
(C) is wrong. Adequate sleep is not a prevention (D) for confusion.)
A postoperative client will need to perform daily dressing changes after discharge.
Which outcome statement best demonstrates the client's readiness to manage his
wound care after discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care
C. demonstrates the wound care procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the
client's ability to perform a task, while (A and B) are subjective measures. (D) is
important, but is less of a priority than the nurse's assessment of the client's ability
to complete wound care.)
A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next
day. What question is most important for the nurse to include during the
preoperative assessment?
A. What is your daily calorie consumption?
B. What vitamin and mineral supplements do you take?"
C. "Do you feel that you are overweight?"
D. "Will a clear liquid diet be okay after surgery?"
