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Hesi Fundamentals Practice Test 2024/2025 graded A+
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Hesi Fundamentals Practice Test 2024/2025 graded A+
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Hesi Fundamentals Practice TestAn elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. - ANSTo avoid shearing forces
when repositioning, the client should be lifted gently across a surface (D). Reddened areas
should not be massaged (A) since this may increase the damage to already traumatized
skin. To control pain and muscle spasms, active range of motion (B) may be limited on the
affected leg. The position described in (C) is contraindicated for a client with a fractured left
hip.
Correct Answer: D
The nurse is administering medications through a nasogastric tube (NGT) which is
connected to suction. After ensuring correct tube placement, what action should the nurse
take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - ANSThe NGT should be flushed before,
after and in between each medication administered (B). Once all medications are
administered, the NGT should be clamped for 20 minutes (A). (C and D) may be
implemented only after the tubing has been flushed.
Correct Answer: B
A client who is in hospice care complains of 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. - ANSThe most
effective management of pain is achieved using an around-the-clock schedule that provides
analgesic medications on a regular basis (A) and in a timely manner. Analgesics are less
effective if pain persists until it is severe, so an analgesic medication should be administered
before the client's pain peaks (B). Providing comfort is a priority for the client who is dying,
but sedation that impairs the client's ability to interact and experience the time before life
ends should be minimized (C). Offering a medication-free period allows the serum drug level
to fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
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. - ANSThe priority nursing action is to restore circulation by
loosening the restraint (A), because blue fingers (cyanosis) indicates decreased circulation.
(C and D) are also important nursing interventions, but do not have the priority of (A). Pulse
oximetry (B) measures the saturation of hemoglobin with oxygen and is not indicated in
situations where the cyanosis is related to mechanical compression (the restraints).
Correct Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - ANSA lactating woman (B) has the
greatest need for additional protein intake. (A, C, and D) are all conditions that require
protein, but do not have the increased metabolic protein demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What
is the best intervention for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. -
ANSTo ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the bloodstream
(D). The nurse should document the reason for the late dose, but (A and C) are not
warranted. (B) could result in increased blood levels of the drug.
Correct Answer: D
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above
and below the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion. - ANSThe wife is performing
the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The joint
that is being exercised should be uncovered (B) while the rest of the body should remain
covered for warmth and privacy. (C and D) do not provide adequate support to the joint while
still allowing for joint movement.
Correct Answer: A
, What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. -
ANSVenous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged, could be
life-threatening. Superficial veins are often very easy (A) to find in the feet and legs.
Handling a leg or foot with an IV (C) is probably not any more difficult than handling an arm
or hand. Even if the nurse did believe moving a cannulated leg was more difficult, this is not
the most important reason for using the upper extremities. Pain (D) is not a consideration.
Correct Answer: B
The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure
with a cuff that is too small, but the blood pressure reading obtained is within the client's
usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - ANSThe most
important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed (A).
Though (C and D) are likely indicated, these actions do not have the priority of (B).
Correct Answer: B
A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB. The preparation arrives from
the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose
over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the
secondary infusion? - ANSThe infusion rate is calculated as a ratio proportion problem, i.e.,
50 ml/ 20 min : x ml/ 60 min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150
Correct Answer: 150
Twenty minutes after beginning a heat application, the client states that the heating pad no
longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body's receptors adapt over time as they are exposed to heat. - ANS(D) describes
thermal adaptation, which occurs 20 to 30 minutes after heat application. (A and B) provide
false information. (C) is not based on a knowledge of physiology and is an unsafe action that
may harm the client.
Correct Answer: D
The nurse is instructing a client with high cholesterol about diet and life style modification.
What comment from the client indicates that the teaching has been effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
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