Hesi Fundamentals 2 Practice Questions WITH VERRIFFIED ANSWERS 2024
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Hesi Fundamentals 2 Practice Questions
WITH VERRIFFIED ANSWERS 2024
,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 ANSWERS-
Answer: a. observe the appearance of the skin under the ice pack
Rationale: the first action taken by the nurse should be to assess the skin for any
possible thermal injury (a). If no injury to the skin has occurred, the nurse can take the
other actions b,c,d as needed.
The nurse mixes 50 mg of Nipride in 250mL of D5W and plans to administer the
solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of
60gtt/mL how many drops per minute should the client receive?
a. 31 gtt/min
b. 62 gtt/min
c. 93 gtt/min
d. 124 gtt/min - CORRECT ANSWERS-Answer: d. 124 gtt/min
Rationale: d is the correct calculation:
182/2.2 = 82.73 kg
5mcg x 82.73 = 413.65 mcg/min.
250/50,000mcg = 200 mcg/ml
413.65/200 = 2.07 mL
60 x 2.07 = 124.28 gtt/min
The healthcare provider prescribes an IV infusion of 1,000mL Ringer's Lactate with 30
units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
infant by caesarean 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?
a. 42 gtt/min
b. 83 gtt/min
c. 125 gtt/min
d. 250 gtt/min - CORRECT ANSWERS-Answer: b. 83 gtt/min
,Rationale:
1000ml / 4 hours = 250 ml/hour
250ml/60 min = 4.1667ml/min
4.1667ml/min x 20 gtt/ml = 83.33 gtt/min
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 ANSWERS-Answer: c. examining a chest x-ray obtained after tubing was
inserted
Rationale: both a and b are methods used to determine proper placement of NG tubing.
However, the best indicator is c.
D is not an indicator of proper placement
Three days following 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 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 - CORRECT ANSWERS-Answer: b. instruct the client that the stoma will
become smaller when the initial swelling diminishes
Rationale: postoperative swelling causes enlargement of the stoma. The nurse can
teach the client that the stoma will become smaller when the 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 NG tube
the last 2 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 - CORRECT
ANSWERS-Answer: b. reposition the client on her side
Rationale: the immediate priority is to determine if the tube is functioning properly, which
could 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 were successful, the client may require an
antiemetic (d).
A hospitalized male patient is receiving nasogastric 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 now feels fine. What action is the 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 HCP
c. after clearing the tube with 30mL 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 ANSWERS-Answer: c. stop the feeding, explain to the family why it is being
stopped, and notify HCP
Rationale: Coughing, vomiting, and suctioning can precipitate displacement of the tip of
the small bore feeding tube upward into the esophagus, placing the client at increased
risk for aspiration. Checking the sample of fluid withdrawn from the tube (after clearing
with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive
method for these tubes, and the nurse should assess tube placement in this way prior to
taking any further action (c). (a) and (b) are not indicated. The auscultating method (d)
has been found to be unreliable for small-bore feeding tubes.
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. demonstrate loss of remote memory
b. exhibits expressive dysphagia
c. has a diminished attention span
d. is disoriented to place and time - CORRECT ANSWERS-Answer: d. is disoriented to
place and time
Rationale: 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 a diminished attention span (c).
A client with chronic kidney disease selects a scrambled egg for his breakfast. What
action should the nurse take?
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