HESI Fundamentals Practice Test/Final 2
(NCLEX) Marking Scheme 2023
An adult is now alert and oriented following abdominal surgery. What position is most
appropriate for the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's - ANS-A
This position allows for greater thoracic expansion and puts less pressure on the suture
line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload - ANS-B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which
action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day - ANS-C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair.
How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed - ANS-A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client?
a. Flat in bed with legs elevated
b. Flat in bed
, c. Trendelenburg position
d. Semi-Fowler's position - ANS-A
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
a. Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV - ANS-B
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential
during tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning - ANS-B--To
prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most
appropriate for the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift - ANS-B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a
tracheostomy tube, the client starts to cough. What is the best action for the nurse to
take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions - ANS-D
During the suctioning of a tracheostomy tube, the catheter appears to attach to the
tracheal walls and creates a pulling sensation. What is the best action for the nurse to
take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper - ANS-A
(NCLEX) Marking Scheme 2023
An adult is now alert and oriented following abdominal surgery. What position is most
appropriate for the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's - ANS-A
This position allows for greater thoracic expansion and puts less pressure on the suture
line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload - ANS-B
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which
action is least appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day - ANS-C
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair.
How should the nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
d. Facing the bed in the left side of the bed - ANS-A
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client?
a. Flat in bed with legs elevated
b. Flat in bed
, c. Trendelenburg position
d. Semi-Fowler's position - ANS-A
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
a. Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV - ANS-B
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential
during tracheal suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning - ANS-B--To
prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most
appropriate for the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift - ANS-B
Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a
tracheostomy tube, the client starts to cough. What is the best action for the nurse to
take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions - ANS-D
During the suctioning of a tracheostomy tube, the catheter appears to attach to the
tracheal walls and creates a pulling sensation. What is the best action for the nurse to
take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper - ANS-A
