Hesi Fundamentals Test 2023
1. The home health nurse visits an elderly female client who had a brain
attack three months ago and is now able to ambulate with the assistance of a
quad cane. Which assessment finding has the greatest implications for this
client's care?
• The husband, who ...
Comprehensive Hesi Fundamentals Test 2024 Graded A
nursing (University of Nairobi)
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Hesi Fundamentals Test 2023
1. The home health nurse visits an elderly female client who had a brain
attack threemonths ago and is now able to ambulate with the assistance of a
quad cane. Which assessment finding has the greatest implications for this
client's care?
• The husband, who is the caregiver, begins to weep when the nurse asks how he is
doing.
• The client tells the nurse that she does not have much of an appetite today.
• The nurse notes that there are numerous scatter rugs throughout the
house.Correct
• The client's pulse rate is 10 beats higher than it was at the last visit one
week ago. Scatter rugs (C) pose a safety hazard because the client can trip on
them when ambulating, so this finding has the greatest significance in
planning this client's care.Psychological support of the caregiver (A) is a less
acute need than that of client safety. The nurse needs to obtain more
information about (B), but this is not a safetyissue. (D) is not a significant
increase, and additional assessment might provide information about the
reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a client. The nurse
should stopthe procedure and take corrective action if which client reaction is
noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the
anal sphincter, which should be stopped if the client experiences a vagal
response, such asbradycardia (B). (A, C, and D) do not warrant stopping the
procedure.
3. The nurse is providing passive range of motion (ROM) exercises to the hip
and knee for a client who is unconscious. After supporting the client's knee
with one hand,what action should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct
Passive ROM exercise for the hip and knee is provided by supporting the
joints of theknee and ankle (D) and gently moving the limb in a slow,
smooth, firm but gentle manner. (A) should be done before the exercises are
begun to prevent injury to the nurse and client. (B) is carried out after both
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joints are supported. After the knee is
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bent, then the knee is moved toward the chest to the point of resistance
(C) two orthree times.
4. A client who has moderate, persistent, chronic neuropathic pain due to
diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin,
Advil) daily. If Step2 of the World Health Organization (WHO) pain relief
ladder is prescribed, which drug protocol should be implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin (Neurontin), an antiseizure medication, may be used at any step
for anxiety and pain management, so (A) should be implemented. Nonopiod
analgesics, such as ibuprofen
(A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics
(D), and tomaintain freedom from pain, drugs should be given around the
clock rather than by the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling urinary catheter
using anopen technique. What action should the nurse take after
applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe. Correct
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution.
To irrigate an indwelling urinary catheter, the nurse should first apply gloves,
then draw up the irrigating solution into the syringe (B). The syringe is then
attached to thecatheter and the fluid instilled, using aseptic technique (D).
Once the irrigating solution is instilled, the client's catheter should be secured
to the drainage tubing (C). The urinary drainage bag can be emptied (A)
whenever intake and output measurement is indicated, and the instilled
irrigating fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier gloves as
required by theprotocol for Standard Precautions?
• Removing the empty food tray from a client with a urinary catheter.
• Washing and combing the hair of a client with a fractured leg in traction.
• Administering oral medications to a cooperative client with a wound infection.
• Emptying the urinary catheter drainage bag for a client with
Alzheimer'sdisease. Correct
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