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HESI FUNDAMENTALS PRACTISE EXAM 2024/2025 graded A+
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HESI FUNDAMENTALS PRACTISE EXAM 2024/2025 graded A+
[Meer zien]Voorbeeld 3 van de 18 pagina's
Voorbeeld 3 van de 18 pagina's
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Voorbeeld van de inhoud
HESI FUNDAMENTALS PRACTICE EXAMThe nurse observes that a male client has removed the covering from an ice park 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. - ANSObserve the appearance of
the skin under the ice pack (The first action taken by the nurse should be to assess the skin
for any possible thermal injury. If no injury to the skin has occurred, the nurse can take the
other actions.)
The nurse mixes 50 mg of Nipride in 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? - ANS124 gtt/min
The healthcare provider prescribes 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? - ANS83 gtt/min
Which assessment data provides the most accurate determination of proper placement of a
nasogastric tube? - ANSExamining a chest x-ray obtained after the tubing was inserted
Three days following a surgery, a male client observes his colostomy for the first time. He
becomes quite upset and tells the nurse that it is much bigger than he expected. What is the
best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma 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. - ANSB. Instruct the client that the stoma will become smaller when the initial
swelling diminishes (Postoperative swelling causes enlargement of the stoma. The nurse
can teach the client that the stoma will become smaller when swelling is diminished (B). This
will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not
provide helpful teaching or support. (C) is a useful action, and may be taken after the nurse
provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy
care. (D)
A female client with a nasogastric tube attached to low suction states that she is nauseated.
The nurse assesses that there has been no drainage through the nasogastric tube in the last
two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
,B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use. - ANSB. Reposition the
client on her side. (The immediate priority is to determine if the tube is functioning correctly,
which would then relieve the client's nausea. The least invasive intervention (B) should be
attempted first, followed by (A and C), unless either of these interventions is contraindicated.
If these measures are unsuccessful, the client may require an antiemetic (D))
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 HCP.
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. - ANSC.
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
A male client tells the nurse that he does not know where he is or what year it is. What data
should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
D. is disoriented to place and time - ANSD. is disoriented to place and time (The client is
exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to
express himself without difficulty (B), and does not demonstrate diminished attention span.
(C).
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast. What
action should the nurse take?
A. Commend the client for selecting a high biologic value protein.
B. Remind the client that protein in the diet should be avoided.
C. Suggest that the client also select orange juice, to promote absorption.
D. Encourage the client to attend classes on dietary management of CKD. - ANSA.
Commend the client for selecting a high biologic value protein. (Foods such as eggs and
milk (A) are high biologic proteins which are allowed because they are complete proteins
and supply the essential amino acids that are necessary for growth and cell repair. Orange
juice is rich in potassium and should not be encouraged. The client has made a good diet
choice so (D) is not necessary.)
When assisting an 82 year old client to ambulate, it is important for the nurse to realize that
the center of gravity for an elderly person is the-- - ANSUpper torso (The center of gravity for
adults is the hips. However, as the person grows older, a stooped posture is common
because of the changes from osteoporosis and normal bone degeneration, and the knees,
hips, and elbows flex. This stooped posture results in the upper torso becoming the center of
gravity for older persons.)
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
, A. is to be expected, and progresses with age
B. often follows relocation to new surroundings
C. is a result of irreversible brain pathology
D. can be prevented with adequate sleep - ANSB. often follows relocation to new
surroundings (Relocation (B) often results in confusion among elderly clients-- moving is
stressful for anyone. (A) is stereotypical judgement. Stress in the elderly often manifests
itself as confusion, so (C) is wrong. Adequate sleep is not a prevention (D) for confusion.)
A postoperative client will need to perform daily dressing changes after discharge. Which
outcome statement best demonstrates the client's readiness to manage his wound care after
discharge? The client
A. asks relevant questions regarding the dressing change
B. states he will be able to complete the wound care regimen
C. demonstrates the wound care procedure correctly
D. has all the necessary supplies for wound care - ANSC. demonstrates the wound care
procedure correctly
(A return demonstration of a procedure (C) provides an objective assessment of the client's
ability to perform a task, while (A and B) are subjective measures. (D) is important, but is
less of a priority than the the nurse's assessment of the client's ability to complete wound
care.)
A client who is 5 '5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment?
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?" - ANSB. "What vitamin and mineral
supplements do you take?"
(Vitamin and mineral supplements (B) may impact medications used during the operative
period. (A and C) are appropriate questions for long-term dietary counseling. The nature of
the surgery and anesthesia will determine the need for a clear liquid diet (D), rather than the
client's preference.)
During the initial morning assessment, a male client denies dysuria but reports that his urine
appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water. - ANSD. Encourage additional oral
intake of juices and water.
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention?
A. Apply a condom catheter
B. Apply a skin protectant
C. Encourage increased fluid intake
D. Assess for bladder distention - ANSD. Assess the bladder for distention (Urinary retention
is the inability to void all urine collected in the bladder, which leads to uncomfortable bladder
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