ALL HESI FUNDAMENTALS EXAM SPRING
2023.TEST BANK UPDATED Assured Correct
AnswersTOPTARGET ACADEMIC
UNIT 1: SAFETY, MOBILITY & RESTRAINTS
1. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client’s care?
A) Massage any reddened areas for at least five minutes.
B) Encourage active range of motion exercises on the affected extremity.
C) Position the client laterally, prone, and dorsally in sequence.
D) Gently lift the client when moving into a desired position.
Correct Answer: D
Rationale: To avoid shearing forces when repositioning, the client should be lifted gently
across a surface. Reddened areas should never be massaged, as this may increase damage to
already traumatized skin. Active range of motion may be limited on the affected leg due to pain
and muscle spasms. The positioning described in option C is contraindicated for a client with a
fractured hip.
2. When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
A) Loosen the right wrist restraint.
B) Apply a pulse oximeter to the right hand.
C) Compare hand color bilaterally.
D) Palpate the right radial pulse.
Correct Answer: A
Rationale: Blue fingers indicate cyanosis and decreased circulation from the restraint. The
priority nursing action is to restore circulation by loosening the restraint immediately. While
comparing hand color and palpating the radial pulse are important assessments, they should
occur after restoring circulation. Pulse oximetry measures hemoglobin saturation and is not the
priority when cyanosis is related to mechanical compression.
,3. A nurse is preparing to transfer a heavy, immobile patient from bed to chair. Which action
best protects the nurse’s back?
A) Use proper body mechanics with back straight and knees bent.
B) Transfer the patient independently, slowly and carefully.
C) Slide the patient down in bed, then lift from the knees.
D) Use a mechanical lift device designed for patient transfers.
Correct Answer: D
Rationale: Current guidelines emphasize that relying on body mechanics alone is insufficient
to prevent back injury. Mechanical lift devices are recommended for patient transfers to protect
the nurse’s musculoskeletal health. Even with proper form, heavy lifts carry significant injury
risk.
4. When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A) Place the chair parallel to the bed, with its back toward the head of the bed.
B) With the nurse’s feet spread apart and knees aligned with the client’s knees, stand and pivot
the client into the chair.
C) Assist the client to a standing position by gently lifting upward underneath the axillae.
D) Stand beside the client, place the client’s arms around the nurse’s neck, and gently move the
client to the chair.
Correct Answer: B
Rationale: Option B describes the correct positioning of the nurse and affords a wide base
of support while stabilizing the client’s knees when assisting to a standing position. The chair
should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of
the bed. Clients should never be lifted under the axillae, as this could damage nerves and strain
the nurse’s back. The client should never place their arms around the nurse’s neck.
5. The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom
door, he states, “I feel faint.” Before the nurse can get the client to a chair, the client starts to
fall. Which is the priority action for the nurse to take?
,A) Check the client’s carotid pulse.
B) Encourage the client to get to the toilet.
C) In a loud voice, call for help.
D) Gently lower the client to the floor.
Correct Answer: D
Rationale: The priority is to prevent injury to both the client and the nurse. Safely lowering
the client to the floor is the most prudent action when the client cannot support his own
weight. Checking a pulse is an assessment that should be performed after the client is in a safe
position. Encouraging movement is unsafe when the client is fainting. Calling for help may cause
alarm and is secondary to preventing a fall.
6. A client who is 2 days postoperative following a hip replacement is prescribed a sequential
compression device (SCD). The nurse notes that the client has removed the SCDs. Which
finding should the nurse prioritize?
A) The client’s report of discomfort from the SCDs
B) The client’s knowledge of the purpose of the SCDs
C) The client’s need for assistance with putting the SCDs back on
D) The risk of venous thromboembolism (VTE) without the SCDs
Correct Answer: D
Rationale: The priority is the client’s risk of VTE without the SCDs. The nurse should first
address the clinical risk and reinforce the importance of DVT prophylaxis. After ensuring safety,
the nurse should assess the client’s comfort and knowledge to address the underlying reason
for removal.
7. The nurse observes an unlicensed assistive personnel (UAP) taking a client’s blood pressure
in the lower extremity. Which observation requires the nurse to intervene?
A) The cuff wraps around the girth of the leg.
B) The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C) The client is placed in a prone position.
D) The systolic reading is 20 mm Hg higher than the blood pressure in the client’s arm.
Correct Answer: B
, Rationale: When obtaining a blood pressure in the lower extremity, the nurse should
auscultate the popliteal pulse with the cuff on the lower thigh, not the lower leg. The cuff
should wrap around the girth of the leg, the client may be prone or supine, and a systolic
reading 20 mm Hg higher than the arm is a normal finding.
8. Which client is at the greatest risk for falls?
A) A 35-year-old client who is 2 days postoperative for an appendectomy
B) A 72-year-old client taking diuretics and a sedative
C) A 45-year-old client with a fractured arm in a cast
D) A 28-year-old client receiving IV antibiotics
Correct Answer: B
Rationale: Advanced age, diuretic use (which can cause urgency and hypotension), and
sedative use (which impairs alertness and balance) are significant risk factors for falls. The other
clients have acute but less compounding fall risks.
9. A nurse is teaching a client about using a cane. Which instruction should the nurse include?
A) Hold the cane on the affected side.
B) Advance the cane 6 to 10 inches forward before moving the affected leg.
C) Hold the cane on the unaffected side and move it with the affected leg.
D) Use the cane only when climbing stairs.
Correct Answer: C
Rationale: The cane should be held on the unaffected (strong) side to provide support while
the affected leg bears weight. The cane is advanced forward simultaneously with the affected
leg. The cane is used for general ambulation, not only for stairs.
10. The nurse is caring for a client with a new below-the-knee amputation. Which
intervention is most important to prevent contractures?
A) Encourage the client to sit in a chair for prolonged periods.
B) Place a pillow under the residual limb to elevate it.
C) Encourage the client to lie prone several times daily.
D) Apply heat to the residual limb every 4 hours.
2023.TEST BANK UPDATED Assured Correct
AnswersTOPTARGET ACADEMIC
UNIT 1: SAFETY, MOBILITY & RESTRAINTS
1. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client’s care?
A) Massage any reddened areas for at least five minutes.
B) Encourage active range of motion exercises on the affected extremity.
C) Position the client laterally, prone, and dorsally in sequence.
D) Gently lift the client when moving into a desired position.
Correct Answer: D
Rationale: To avoid shearing forces when repositioning, the client should be lifted gently
across a surface. Reddened areas should never be massaged, as this may increase damage to
already traumatized skin. Active range of motion may be limited on the affected leg due to pain
and muscle spasms. The positioning described in option C is contraindicated for a client with a
fractured hip.
2. When assessing a client with wrist restraints, the nurse observes that the fingers on the
right hand are blue. What action should the nurse implement first?
A) Loosen the right wrist restraint.
B) Apply a pulse oximeter to the right hand.
C) Compare hand color bilaterally.
D) Palpate the right radial pulse.
Correct Answer: A
Rationale: Blue fingers indicate cyanosis and decreased circulation from the restraint. The
priority nursing action is to restore circulation by loosening the restraint immediately. While
comparing hand color and palpating the radial pulse are important assessments, they should
occur after restoring circulation. Pulse oximetry measures hemoglobin saturation and is not the
priority when cyanosis is related to mechanical compression.
,3. A nurse is preparing to transfer a heavy, immobile patient from bed to chair. Which action
best protects the nurse’s back?
A) Use proper body mechanics with back straight and knees bent.
B) Transfer the patient independently, slowly and carefully.
C) Slide the patient down in bed, then lift from the knees.
D) Use a mechanical lift device designed for patient transfers.
Correct Answer: D
Rationale: Current guidelines emphasize that relying on body mechanics alone is insufficient
to prevent back injury. Mechanical lift devices are recommended for patient transfers to protect
the nurse’s musculoskeletal health. Even with proper form, heavy lifts carry significant injury
risk.
4. When assisting a client from the bed to a chair, which procedure is best for the nurse to
follow?
A) Place the chair parallel to the bed, with its back toward the head of the bed.
B) With the nurse’s feet spread apart and knees aligned with the client’s knees, stand and pivot
the client into the chair.
C) Assist the client to a standing position by gently lifting upward underneath the axillae.
D) Stand beside the client, place the client’s arms around the nurse’s neck, and gently move the
client to the chair.
Correct Answer: B
Rationale: Option B describes the correct positioning of the nurse and affords a wide base
of support while stabilizing the client’s knees when assisting to a standing position. The chair
should be placed at a 45-degree angle to the bed, with the back of the chair toward the head of
the bed. Clients should never be lifted under the axillae, as this could damage nerves and strain
the nurse’s back. The client should never place their arms around the nurse’s neck.
5. The nurse is assisting a client to the bathroom. When the client is 5 feet from the bathroom
door, he states, “I feel faint.” Before the nurse can get the client to a chair, the client starts to
fall. Which is the priority action for the nurse to take?
,A) Check the client’s carotid pulse.
B) Encourage the client to get to the toilet.
C) In a loud voice, call for help.
D) Gently lower the client to the floor.
Correct Answer: D
Rationale: The priority is to prevent injury to both the client and the nurse. Safely lowering
the client to the floor is the most prudent action when the client cannot support his own
weight. Checking a pulse is an assessment that should be performed after the client is in a safe
position. Encouraging movement is unsafe when the client is fainting. Calling for help may cause
alarm and is secondary to preventing a fall.
6. A client who is 2 days postoperative following a hip replacement is prescribed a sequential
compression device (SCD). The nurse notes that the client has removed the SCDs. Which
finding should the nurse prioritize?
A) The client’s report of discomfort from the SCDs
B) The client’s knowledge of the purpose of the SCDs
C) The client’s need for assistance with putting the SCDs back on
D) The risk of venous thromboembolism (VTE) without the SCDs
Correct Answer: D
Rationale: The priority is the client’s risk of VTE without the SCDs. The nurse should first
address the clinical risk and reinforce the importance of DVT prophylaxis. After ensuring safety,
the nurse should assess the client’s comfort and knowledge to address the underlying reason
for removal.
7. The nurse observes an unlicensed assistive personnel (UAP) taking a client’s blood pressure
in the lower extremity. Which observation requires the nurse to intervene?
A) The cuff wraps around the girth of the leg.
B) The UAP auscultates the popliteal pulse with the cuff on the lower leg.
C) The client is placed in a prone position.
D) The systolic reading is 20 mm Hg higher than the blood pressure in the client’s arm.
Correct Answer: B
, Rationale: When obtaining a blood pressure in the lower extremity, the nurse should
auscultate the popliteal pulse with the cuff on the lower thigh, not the lower leg. The cuff
should wrap around the girth of the leg, the client may be prone or supine, and a systolic
reading 20 mm Hg higher than the arm is a normal finding.
8. Which client is at the greatest risk for falls?
A) A 35-year-old client who is 2 days postoperative for an appendectomy
B) A 72-year-old client taking diuretics and a sedative
C) A 45-year-old client with a fractured arm in a cast
D) A 28-year-old client receiving IV antibiotics
Correct Answer: B
Rationale: Advanced age, diuretic use (which can cause urgency and hypotension), and
sedative use (which impairs alertness and balance) are significant risk factors for falls. The other
clients have acute but less compounding fall risks.
9. A nurse is teaching a client about using a cane. Which instruction should the nurse include?
A) Hold the cane on the affected side.
B) Advance the cane 6 to 10 inches forward before moving the affected leg.
C) Hold the cane on the unaffected side and move it with the affected leg.
D) Use the cane only when climbing stairs.
Correct Answer: C
Rationale: The cane should be held on the unaffected (strong) side to provide support while
the affected leg bears weight. The cane is advanced forward simultaneously with the affected
leg. The cane is used for general ambulation, not only for stairs.
10. The nurse is caring for a client with a new below-the-knee amputation. Which
intervention is most important to prevent contractures?
A) Encourage the client to sit in a chair for prolonged periods.
B) Place a pillow under the residual limb to elevate it.
C) Encourage the client to lie prone several times daily.
D) Apply heat to the residual limb every 4 hours.
