ESTUDYR
HESI LPN–ADN MOBILITY EXAM FOUNDATIONS OF
NURSING (HESI TRANSITION)
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.
Rationale: Chest x-ray is the gold standard to confirm NG/enteric tube placement and most
accurate; pH/air methods are supportive but less definitive.
When assisting an 82-year-old client to ambulate, the nurse should realize the center of
gravity for an elderly person is the:
A. Arms.
B. Upper torso.
C. Head.
D. Feet.
Rationale: Age-related stooped posture shifts the center of gravity upward toward the upper
torso (hips in younger adults).
Which action is most important when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first.
Rationale: Sterile field is above waist/waist level; keeping hands above elbows prevents
contamination.
An adult with hypertension wants to try spiritual meditation instead of meds. Nurse’s first
response should be:
A. “It is important that you continue your medication while learning to meditate.”
B. “Spiritual meditation requires 15–20 minutes daily.”
C. “Obtain your healthcare provider’s permission before starting meditation.”
D. “Complementary therapy and western medicine can be effective for you.”
Rationale: Prevents abrupt med cessation; continue meds while monitoring effects of any
complementary therapy.
,ESTUDYR
A primary source for health assessment information is the:
A. Client.
B. Healthcare provider.
C. A family member.
D. Previous medical records.
Rationale: The client is the primary (first-hand) source; others are secondary.
Teaching effectiveness for a client with high cholesterol is demonstrated by which
statement?
A. “If I exercise two times weekly for one hour, I will lower my cholesterol.”
B. “I need to avoid eating proteins, including red meat.”
C. “I will limit my intake of beef to 4 ounces per week.”
D. “My blood level of low density lipoproteins needs to increase.”
Rationale: Limiting saturated fat/portion control is correct; LDL should decrease.
A rash of multiple flat red areas 0.5 cm or less should be recorded as:
A. Multiple vesicular areas surrounded by redness...
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions...
D. Localized petechial areas...
Rationale: Flat discolorations <1 cm are macules; description should be descriptive rather than
only the label.
A client 5'5" and 200 lb scheduled for surgery — most important preop question:
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?”
Rationale: Nutritional/caloire intake helps assess obesity risks and perioperative nutrition;
supplements also important but calorie intake informs risk most.
After nasotracheal suctioning for 15 seconds, large thick secretions return. Next action:
A. Encourage coughing.
B. Advise increased oral fluids.
C. Rotate the suction catheter.
D. Re-oxygenate the client before attempting to suction again.
Rationale: Limit suction duration to avoid hypoxia; reoxygenate first before repeat suctioning.
Client receiving small-bore continuous NG tube feedings coughs violently. Best nurse
action:
,ESTUDYR
A. Record and do nothing.
B. Stop feeding and notify provider.
C. After clearing tube with 30 mL air, check pH of aspirate.
D. Inject 30 mL air and auscultate epigastrium.
Rationale: Coughing can displace tube; checking aspirate pH confirms gastric placement—
auscultation (air method) is unreliable for small-bore tubes.
Client with NG tube on low suction reports nausea, and there has been no drainage for 2
hours. First action:
A. Irrigate tube with sterile saline.
B. Reposition the client on her side.
C. Advance the tube 5 cm.
D. Give IV antiemetic PRN.
Rationale: Least invasive — repositioning can relieve kinking/occlusion; irrigation or
advancement after assessing for contraindications.
Safest method to transfer an elderly client with left-sided weakness from bed to chair:
A. Place chair at right angle to bed on client's left side.
B. Assist client to standing then place right hand on armrest.
C. Have client place left foot next to chair and pivot left.
D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Rationale: Use the stronger (right) side for weight-bearing and pivoting; parallel placement
facilitates safe transfer.
Accurate statement about complementary healing practices:
A. They interfere with conventional treatment.
B. Conventional meds will interact with folk remedies and cause adverse effects.
C. Many complementary practices can be used in conjunction with conventional practices.
D. Conventional practices will replace complementary practices.
Rationale: Many complementary therapies are adjuncts; evaluate interactions case-by-case.
After assessment and identifying a client problem, the nurse’s next action is to:
A. Determine the etiology of the problem.
B. Prioritize nursing interventions.
C. Plan interventions.
D. Collaborate with client to set goals.
Rationale: Identify cause (etiology) so interventions and goals target underlying issue.
Hispanic parents offer only broth to a post-op toddler; best cultural explanation:
A. Fear of the “evil eye.”
, ESTUDYR
B. Child refused other foods.
C. Eating broth strengthens “chi.”
D. Hot remedies restore balance after surgery, considered "cold."
Rationale: Many cultures classify conditions as hot/cold; surgery is “cold,” so warm foods are
preferred.
Three days after surgery a client is upset that his colostomy looks large. Best nurse
response:
A. Reassure he’ll become accustomed.
B. Instruct that the stoma will decrease as swelling diminishes.
C. Offer ostomy support group contact.
D. Encourage handling stoma equipment now.
Rationale: Teaching about expected postoperative swelling reduces anxiety and is immediately
helpful.
UAP positions client in left lateral before soap suds enema; nurse should instruct:
A. Position on right side in reverse Trendelenburg.
B. Fill enema with 1000 mL warm water + 5 mL soap.
C. Reposition in Sim’s position with client’s weight on anterior ilium.
D. Raise side rails and elevate bed to waist level.
Rationale: Left Sims optimizes flow of enema solution through sigmoid colon; weight should be
on anterior ilium.
Heparin 20,000 units in 500 mL D5W at 50 mL/hr infused 5.5 hours. Units delivered =
A. 11,000 units.
B. 13,000 units.
C. 15,000 units.
D. 17,000 units. (Wait — compute below)
Correction & Rationale: Calculate: Rate 50 mL/hr × 5.5 hr = 275 mL infused. Concentration =
20,000 units / 500 mL = 40 units/mL. Units delivered = 275 mL × 40 units/mL = 11,000 units.
Correct answer = A. 11,000 units.
(Earlier listed options included A=11,000 — A is correct.)
A male client cannot identify where he is or year. Most accurate documentation:
A. Demonstrates loss of remote memory.
B. Exhibits expressive dysphasia.
C. Has a diminished attention span.
D. Is disoriented to place and time.
Rationale: Disorientation to place/time best describes inability to identify location and time.
HESI LPN–ADN MOBILITY EXAM FOUNDATIONS OF
NURSING (HESI TRANSITION)
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.
Rationale: Chest x-ray is the gold standard to confirm NG/enteric tube placement and most
accurate; pH/air methods are supportive but less definitive.
When assisting an 82-year-old client to ambulate, the nurse should realize the center of
gravity for an elderly person is the:
A. Arms.
B. Upper torso.
C. Head.
D. Feet.
Rationale: Age-related stooped posture shifts the center of gravity upward toward the upper
torso (hips in younger adults).
Which action is most important when donning sterile gloves?
A. Maintain thumb at a ninety degree angle.
B. Hold hands with fingers down while gloving.
C. Keep gloved hands above the elbows.
D. Put the glove on the dominant hand first.
Rationale: Sterile field is above waist/waist level; keeping hands above elbows prevents
contamination.
An adult with hypertension wants to try spiritual meditation instead of meds. Nurse’s first
response should be:
A. “It is important that you continue your medication while learning to meditate.”
B. “Spiritual meditation requires 15–20 minutes daily.”
C. “Obtain your healthcare provider’s permission before starting meditation.”
D. “Complementary therapy and western medicine can be effective for you.”
Rationale: Prevents abrupt med cessation; continue meds while monitoring effects of any
complementary therapy.
,ESTUDYR
A primary source for health assessment information is the:
A. Client.
B. Healthcare provider.
C. A family member.
D. Previous medical records.
Rationale: The client is the primary (first-hand) source; others are secondary.
Teaching effectiveness for a client with high cholesterol is demonstrated by which
statement?
A. “If I exercise two times weekly for one hour, I will lower my cholesterol.”
B. “I need to avoid eating proteins, including red meat.”
C. “I will limit my intake of beef to 4 ounces per week.”
D. “My blood level of low density lipoproteins needs to increase.”
Rationale: Limiting saturated fat/portion control is correct; LDL should decrease.
A rash of multiple flat red areas 0.5 cm or less should be recorded as:
A. Multiple vesicular areas surrounded by redness...
B. Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C. Several areas of red, papular lesions...
D. Localized petechial areas...
Rationale: Flat discolorations <1 cm are macules; description should be descriptive rather than
only the label.
A client 5'5" and 200 lb scheduled for surgery — most important preop question:
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?”
Rationale: Nutritional/caloire intake helps assess obesity risks and perioperative nutrition;
supplements also important but calorie intake informs risk most.
After nasotracheal suctioning for 15 seconds, large thick secretions return. Next action:
A. Encourage coughing.
B. Advise increased oral fluids.
C. Rotate the suction catheter.
D. Re-oxygenate the client before attempting to suction again.
Rationale: Limit suction duration to avoid hypoxia; reoxygenate first before repeat suctioning.
Client receiving small-bore continuous NG tube feedings coughs violently. Best nurse
action:
,ESTUDYR
A. Record and do nothing.
B. Stop feeding and notify provider.
C. After clearing tube with 30 mL air, check pH of aspirate.
D. Inject 30 mL air and auscultate epigastrium.
Rationale: Coughing can displace tube; checking aspirate pH confirms gastric placement—
auscultation (air method) is unreliable for small-bore tubes.
Client with NG tube on low suction reports nausea, and there has been no drainage for 2
hours. First action:
A. Irrigate tube with sterile saline.
B. Reposition the client on her side.
C. Advance the tube 5 cm.
D. Give IV antiemetic PRN.
Rationale: Least invasive — repositioning can relieve kinking/occlusion; irrigation or
advancement after assessing for contraindications.
Safest method to transfer an elderly client with left-sided weakness from bed to chair:
A. Place chair at right angle to bed on client's left side.
B. Assist client to standing then place right hand on armrest.
C. Have client place left foot next to chair and pivot left.
D. Move the chair parallel to the right side of the bed, and stand the client on the right foot.
Rationale: Use the stronger (right) side for weight-bearing and pivoting; parallel placement
facilitates safe transfer.
Accurate statement about complementary healing practices:
A. They interfere with conventional treatment.
B. Conventional meds will interact with folk remedies and cause adverse effects.
C. Many complementary practices can be used in conjunction with conventional practices.
D. Conventional practices will replace complementary practices.
Rationale: Many complementary therapies are adjuncts; evaluate interactions case-by-case.
After assessment and identifying a client problem, the nurse’s next action is to:
A. Determine the etiology of the problem.
B. Prioritize nursing interventions.
C. Plan interventions.
D. Collaborate with client to set goals.
Rationale: Identify cause (etiology) so interventions and goals target underlying issue.
Hispanic parents offer only broth to a post-op toddler; best cultural explanation:
A. Fear of the “evil eye.”
, ESTUDYR
B. Child refused other foods.
C. Eating broth strengthens “chi.”
D. Hot remedies restore balance after surgery, considered "cold."
Rationale: Many cultures classify conditions as hot/cold; surgery is “cold,” so warm foods are
preferred.
Three days after surgery a client is upset that his colostomy looks large. Best nurse
response:
A. Reassure he’ll become accustomed.
B. Instruct that the stoma will decrease as swelling diminishes.
C. Offer ostomy support group contact.
D. Encourage handling stoma equipment now.
Rationale: Teaching about expected postoperative swelling reduces anxiety and is immediately
helpful.
UAP positions client in left lateral before soap suds enema; nurse should instruct:
A. Position on right side in reverse Trendelenburg.
B. Fill enema with 1000 mL warm water + 5 mL soap.
C. Reposition in Sim’s position with client’s weight on anterior ilium.
D. Raise side rails and elevate bed to waist level.
Rationale: Left Sims optimizes flow of enema solution through sigmoid colon; weight should be
on anterior ilium.
Heparin 20,000 units in 500 mL D5W at 50 mL/hr infused 5.5 hours. Units delivered =
A. 11,000 units.
B. 13,000 units.
C. 15,000 units.
D. 17,000 units. (Wait — compute below)
Correction & Rationale: Calculate: Rate 50 mL/hr × 5.5 hr = 275 mL infused. Concentration =
20,000 units / 500 mL = 40 units/mL. Units delivered = 275 mL × 40 units/mL = 11,000 units.
Correct answer = A. 11,000 units.
(Earlier listed options included A=11,000 — A is correct.)
A male client cannot identify where he is or year. Most accurate documentation:
A. Demonstrates loss of remote memory.
B. Exhibits expressive dysphasia.
C. Has a diminished attention span.
D. Is disoriented to place and time.
Rationale: Disorientation to place/time best describes inability to identify location and time.
