Fundamentals Practice Exam (HESI)
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 healthcare provider.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.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. - (correct Answer) - c
The nurse observes that a male client has removed the covering from an ice pack 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. - (correct Answer) - a
Which action is most important for the nurse to implement 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. - (correct Answer) - c
A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an
analgesic every four hours as needed. Which action should the nurse implement?
a. Give an around-the-clock schedule for administration of analgesics.
b. Administer analgesic medication as needed when the pain is severe.
c. Provide medication to keep the client sedated and unaware of stimuli.
d. Offer a medication-free period so that the client can do daily activities. - (correct Answer) - a
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse,
"I don't want any more blood taken for those useless tests." Which narrative documentation should the
nurse enter in the client's medical record?
a. Healthcare provider notified of failure to collect specimens for prescribed blood studies.
,b. Blood specimens not collected because client no longer wants blood tests performed.
c. Healthcare provider notified of client's refusal to have blood specimens collected for testing.
d. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified. -
(correct Answer) - c
The nurse plans to obtain health assessment information from a primary source. Which option is a
primary source for the completion of the health assessment?
a. client
b. healthcare provider
c. a family member
d. previous medical records - (correct Answer) - a
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a
goniometer. Which finding should the nurse expect to measure?
A. Adequate venous blood flow to the lower extremities.
B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client's knee joint.
D. Change in the circumference of the joint in centimeters. - (correct Answer) - c
A female client asks the nurse to find someone who can translate her treatment concerns into her native
language. Which action should the nurse take?
a. Explain that anyone who speaks her language can answer her questions.
b. Provide a translator only in an emergency situation.
c. Ask a family member or friend of the client to translate.
d. Request and document the name of the certified translator. - (correct Answer) - d
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care
unit (PACU). When should the nurse document the client's findings?
a. At the beginning, middle, and end of the shift.
b. After client priorities are identified for the development of the nursing care plan.
c. At the end of the shift so full attention can be given to the client's needs.
d. Immediately after the assessments are completed - (correct Answer) - d
An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral
feedings through a gastrostomy tube (GT). What is the best position for the client for administration of
, the bolus tube feedings?
a. prone
b. fowler's
c. sim's
d. supine - (correct Answer) - b
Which assessment data provides 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. - (correct
Answer) - c
_______ A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups.
The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is
available as 5 mg/ml. A measuring device marked in teaspoons is being used. How many teaspoons
should the nurse administer? - (correct Answer) - 2
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best
explains this nursing responsibility?
a. the client voluntarily signed the form
b. the client fully understands the procedure
c. the client agrees with the procedure to be done
d. the client authorizes continued treatment - (correct Answer) - a
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available
in 5 mg tablets. How much should the nurse plan to administer?
A. ½ tablet.
B. 1 tablet.
C. 1½ tablets.
D. 2 tablets. - (correct Answer) - c
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.
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 healthcare provider.
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. - (correct Answer) - c
The nurse observes that a male client has removed the covering from an ice pack 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. - (correct Answer) - a
Which action is most important for the nurse to implement 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. - (correct Answer) - c
A client who is in hospice care reports increasing amounts of pain. The healthcare provider prescribes an
analgesic every four hours as needed. Which action should the nurse implement?
a. Give an around-the-clock schedule for administration of analgesics.
b. Administer analgesic medication as needed when the pain is severe.
c. Provide medication to keep the client sedated and unaware of stimuli.
d. Offer a medication-free period so that the client can do daily activities. - (correct Answer) - a
A resident in a skilled nursing facility for short-term rehabilitation after a hip replacement tells the nurse,
"I don't want any more blood taken for those useless tests." Which narrative documentation should the
nurse enter in the client's medical record?
a. Healthcare provider notified of failure to collect specimens for prescribed blood studies.
,b. Blood specimens not collected because client no longer wants blood tests performed.
c. Healthcare provider notified of client's refusal to have blood specimens collected for testing.
d. Client irritable, uncooperative, and refuses to have blood collected. Healthcare provider notified. -
(correct Answer) - c
The nurse plans to obtain health assessment information from a primary source. Which option is a
primary source for the completion of the health assessment?
a. client
b. healthcare provider
c. a family member
d. previous medical records - (correct Answer) - a
During a visit to the outpatient clinic, the nurse assesses a client with severe osteoarthritis using a
goniometer. Which finding should the nurse expect to measure?
A. Adequate venous blood flow to the lower extremities.
B. Estimated amount of body fat by an underarm skinfold.
C. Degree of flexion and extension of the client's knee joint.
D. Change in the circumference of the joint in centimeters. - (correct Answer) - c
A female client asks the nurse to find someone who can translate her treatment concerns into her native
language. Which action should the nurse take?
a. Explain that anyone who speaks her language can answer her questions.
b. Provide a translator only in an emergency situation.
c. Ask a family member or friend of the client to translate.
d. Request and document the name of the certified translator. - (correct Answer) - d
At the beginning of the shift, the nurse assesses a client who is admitted from the post-anesthesia care
unit (PACU). When should the nurse document the client's findings?
a. At the beginning, middle, and end of the shift.
b. After client priorities are identified for the development of the nursing care plan.
c. At the end of the shift so full attention can be given to the client's needs.
d. Immediately after the assessments are completed - (correct Answer) - d
An older client who is unresponsive following a cerebral vascular accident (CVA) is receiving bolus enteral
feedings through a gastrostomy tube (GT). What is the best position for the client for administration of
, the bolus tube feedings?
a. prone
b. fowler's
c. sim's
d. supine - (correct Answer) - b
Which assessment data provides 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. - (correct
Answer) - c
_______ A client with pericardial effusion has phrenic nerve compression resulting in recurrent hiccups.
The healthcare provider prescribes metoclopramide (Reglan) liquid 10 mg PO q 6 hours. Reglan is
available as 5 mg/ml. A measuring device marked in teaspoons is being used. How many teaspoons
should the nurse administer? - (correct Answer) - 2
The nurse witnesses the signature of a client who has signed an informed consent. Which statement best
explains this nursing responsibility?
a. the client voluntarily signed the form
b. the client fully understands the procedure
c. the client agrees with the procedure to be done
d. the client authorizes continued treatment - (correct Answer) - a
The healthcare provider prescribes the diuretic metolazone (Zaroxolyn) 7.5 mg PO. Zaroxolyn is available
in 5 mg tablets. How much should the nurse plan to administer?
A. ½ tablet.
B. 1 tablet.
C. 1½ tablets.
D. 2 tablets. - (correct Answer) - c
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.
