HESI FUNDAMENTALS PRACTICE EXAM
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Terms in this set (80)
,The nurse observes that a male client Observe the appearance of the skin under the ice pack (The first action
has removed the covering from an taken by the nurse should be to assess the skin for any possible thermal
ice park applied to his knee. What injury. If no injury to the skin has occurred, the nurse can take the other
action should the nurse take first? actions.)
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.
The nurse mixes 50 mg of Nipride in 124 gtt/min
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?
,The healthcare provider prescribes 83 gtt/min
an IV infusion of 1000 ml of Ringer's
Lactate w/ 30 units of Pitocin to run in
over 4 hours for a client who has just
delivered a 10 pound infant by
cesarean section. The tubing has
been changed to a 20 gtt/ml
administration set. The nurse plans to
set the flow rate at how many
gtt/min?
Which assessment data provides the Examining a chest x-ray obtained after the tubing was inserted
most accurate determination of
proper placement of a nasogastric
tube?
, Three days following a surgery, a B. Instruct the client that the stoma will become smaller when the initial
male client observes his colostomy swelling diminishes (Postoperative swelling causes enlargement of the
for the first time. He becomes quite stoma. The nurse can teach the client that the stoma will become smaller
upset and tells the nurse that it is when swelling is diminished (B). This will help reduce the client's anxiety
much bigger than he expected. What and promote acceptance of the colostomy. (A) does not provide helpful
is the best response by the nurse? teaching or support. (C) is a useful action, and may be taken after the
A. Reassure the client that he will nurse provides pertinent teaching. The client is not yet demonstrating
become accustomed to the stoma readiness to learn colostomy care. (D)
appearance in time.
B. Instruct the client that the stoma
will become much smaller when the
initial swelling diminishes.
C. Offer to contact a member of the
local ostomy support group to help
him with his concerns.
D. Encourage the client to handle the
stoma equipment to gain confidence
with the procedure.