University of North Georgia NURS 3206
Fundamental HESI
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Which assessment data would provide the most accurate C) Examining a chest x-ray obtained after the tubing was inserted
determination of proper placement of a nasogastric
tube? Both (A and B) are methods used to determine proper placement of the NG
tubing. However, the best indicator that the tubing is properly placed is (C). (D) is
A) Aspirating gastric contents to assure a pH value of 4 not an indicator of proper placement
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.
When assisting an 82-year-old client to ambulate, it is B) Upper torso
important for the nurse to realize that the center of
gravity for an elderly person is the 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
A) Arms. normal bone degeneration, and the knees, hips, and elbows flex. This stooped
B) Upper torso. posture results in the upper torso (B) becoming the center of gravity for older
C) Head. persons. Although (A) is a part, or an extension of the upper torso, this is not the
D) Feet best and most complete answer.
Which action is most important for the nurse to C) Keep gloved hands above the elbows
implement when donning sterile gloves?
Gloved hands held below waist level are considered unsterile (C). (A and B) are
A) Maintain thumb at a ninety degree angle. not essential to maintaining asepsis. While it may be helpful to put the glove on
B) Hold hands with fingers down while gloving. the dominant hand first, it is not necessary to ensure asepsis (D).
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first.
,An adult male client with a history of hypertension tells A) It is important that you continue your medication while learning to meditate
the nurse that he is tired of taking antihypertensive
medications and is going to try spiritual meditation The prolonged practice of meditation may lead to a reduced need for
instead. What should be the nurse's first response? antihypertensive medications. However, the medications must be continued (A)
while the physiologic response to meditation is monitored. (B) is not as important
A) It is important that you continue your medication while as continuing the medication. The healthcare provider should be informed, but
learning to meditate. permission is not required to meditate (C). Although it is true that this
B) Spiritual meditation requires a time commitment of 15 complimentary therapy might be effective (D), it is essential that the client
to 20 minutes daily. continue with antihypertensive medications until the effect of meditation can be
C) Obtain your healthcare provider's permission before measured
starting meditation.
D) Complementary therapy and western medicine can be
effective for you.
The nurse plans to obtain health assessment information A) Client
from a primary source. Which option is a primary source
for the completion of the health assessment? A primary source of information for a health assessment is the client (A). (B, C, and
D) are considered secondary sources about the client's health history, but other
A) Client. details, such as subjective data, can only be provided directly from the client.
B) Healthcare provider.
C) A family member.
D) Previous medical records
The nurse is instructing a client with high cholesterol C) I will limit my intake of beef to 4 ounces per week
about diet and life style modification. What comment
from the client indicates that the teaching has been Limiting saturated fat from animal food sources to no more than 4 ounces per
effective? week (C) is an important diet modification for lowering cholesterol. To be
effective in reducing cholesterol, the client should exercise 30 minutes per day, or
A) If I exercise at least two times weekly for one hour, I at least 4 to 6 times per week (A). Red meat and all proteins do not need to be
will lower my cholesterol. eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red
B) I need to avoid eating proteins, including red meat. meat and smaller portions (2-ounce servings). The low density lipoproteins (D)
C) I will limit my intake of beef to 4 ounces per week. need to decrease rather than increase
D) My blood level of low density lipoproteins needs to
increase.
Examination of a client complaining of itching on his right B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter
arm reveals a rash made up of multiple flat areas of
redness ranging from pinpoint to 0.5 cm in diameter. How Macules are localized flat skin discolorations less than 1 cm in diameter. However,
should the nurse record this finding? when recording such a finding the nurse should describe the appearance (B)
rather than simply naming the condition. (A) identifies vesicles -- fluid filled
A) Multiple vesicular areas surrounded by redness, blisters -- an incorrect description given the symptoms listed. (C) identifies
ranging in size from 1 mm to 0.5 cm. papules -- solid elevated lesions, again not correctly identifying the symptoms.
B) Localized red rash comprised of flat areas, pinpoint to (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not
0.5 cm in diameter. itch, again an incorrect identification
C) Several areas of red, papular lesions from pinpoint to
0.5 cm in size.
D) Localized petechial areas, ranging in size from
pinpoint to 0.5 cm in diameter.
, A client who is 5' 5" tall and weighs 200 pounds is A) What is your daily calorie consumption?
scheduled for surgery the next day. What question is
most important for the nurse to include during the Vitamin and mineral supplements (B) may impact medications used during the
preoperative assessment? 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
A) What is your daily calorie consumption? clear liquid diet (D), rather than the client's preference
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?
The nurse is performing nasotracheal suctioning. After D) Re-oxygenate the client before attempting to suction again
suctioning the client's trachea for fifteen seconds, large
amounts of thick yellow secretions return. What action Suctioning should not be continued for longer than ten to fifteen seconds, since
should the nurse implement next? the client's oxygenation is compromised during this time (D). (A, B, and C) may be
performed after the client is re-oxygenated and additional suctioning is
A) Encourage the client to cough to help loosen performed.
secretions.
B) Advise the client to increase the intake of oral fluids.
C) Rotate the suction catheter to obtain any remaining
secretions.
D) Re-oxygenate the client before attempting to suction
again.
A hospitalized male client is receiving nasogastric tube C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
feedings via a small-bore tube and a continuous pump the tube
infusion. He reports that he had a bad bout of severe
coughing a few minutes ago, but feels fine now. What Coughing, vomiting, and suctioning can precipitate displacement of the tip of the
action is best for the nurse to take? small bore feeding tube upward into the esophagus, placing the client at
increased risk for aspiration. Checking the sample of fluid withdrawn from the
A) Record the coughing incident. No further action is tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline
required at this time. (intestine) values is a more sensitive method for these tubes, and the nurse should
B) Stop the feeding, explain to the family why it is being assess tube placement in this way prior to taking any other action (C). (A and B)
stopped, and notify the healthcare provider. are not indicated. The auscultating method (D) has been found to be unreliable
C) After clearing the tube with 30 ml of air, check the pH for small-bore feeding tubes.
of fluid withdrawn from the tube.
D) Inject 30 ml of air into the tube while auscultating the
epigastrium for gurgling.
A female client with a nasogastric tube attached to low B) Reposition the client on her side
suction states that she is nauseated. The nurse assesses
that there has been no drainage through the nasogastric The immediate priority is to determine if the tube is functioning correctly, which
tube in the last two hours. What action should the nurse would then relieve the client's nausea. The least invasive intervention, (B), should
take first? 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
A) Irrigate the nasogastric tube with sterile normal saline. antiemetic (D).
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.
Fundamental HESI
Save
Students also studied
CNA Critical Care: Chapter 4 IV therapy fluids blood high alert Chapte
25 terms 47 terms 50 terms 74 terms
mmramirez956 Preview Alexis_Campbell358 Preview ccarpenter6965 Preview ape
Which assessment data would provide the most accurate C) Examining a chest x-ray obtained after the tubing was inserted
determination of proper placement of a nasogastric
tube? Both (A and B) are methods used to determine proper placement of the NG
tubing. However, the best indicator that the tubing is properly placed is (C). (D) is
A) Aspirating gastric contents to assure a pH value of 4 not an indicator of proper placement
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.
When assisting an 82-year-old client to ambulate, it is B) Upper torso
important for the nurse to realize that the center of
gravity for an elderly person is the 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
A) Arms. normal bone degeneration, and the knees, hips, and elbows flex. This stooped
B) Upper torso. posture results in the upper torso (B) becoming the center of gravity for older
C) Head. persons. Although (A) is a part, or an extension of the upper torso, this is not the
D) Feet best and most complete answer.
Which action is most important for the nurse to C) Keep gloved hands above the elbows
implement when donning sterile gloves?
Gloved hands held below waist level are considered unsterile (C). (A and B) are
A) Maintain thumb at a ninety degree angle. not essential to maintaining asepsis. While it may be helpful to put the glove on
B) Hold hands with fingers down while gloving. the dominant hand first, it is not necessary to ensure asepsis (D).
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first.
,An adult male client with a history of hypertension tells A) It is important that you continue your medication while learning to meditate
the nurse that he is tired of taking antihypertensive
medications and is going to try spiritual meditation The prolonged practice of meditation may lead to a reduced need for
instead. What should be the nurse's first response? antihypertensive medications. However, the medications must be continued (A)
while the physiologic response to meditation is monitored. (B) is not as important
A) It is important that you continue your medication while as continuing the medication. The healthcare provider should be informed, but
learning to meditate. permission is not required to meditate (C). Although it is true that this
B) Spiritual meditation requires a time commitment of 15 complimentary therapy might be effective (D), it is essential that the client
to 20 minutes daily. continue with antihypertensive medications until the effect of meditation can be
C) Obtain your healthcare provider's permission before measured
starting meditation.
D) Complementary therapy and western medicine can be
effective for you.
The nurse plans to obtain health assessment information A) Client
from a primary source. Which option is a primary source
for the completion of the health assessment? A primary source of information for a health assessment is the client (A). (B, C, and
D) are considered secondary sources about the client's health history, but other
A) Client. details, such as subjective data, can only be provided directly from the client.
B) Healthcare provider.
C) A family member.
D) Previous medical records
The nurse is instructing a client with high cholesterol C) I will limit my intake of beef to 4 ounces per week
about diet and life style modification. What comment
from the client indicates that the teaching has been Limiting saturated fat from animal food sources to no more than 4 ounces per
effective? week (C) is an important diet modification for lowering cholesterol. To be
effective in reducing cholesterol, the client should exercise 30 minutes per day, or
A) If I exercise at least two times weekly for one hour, I at least 4 to 6 times per week (A). Red meat and all proteins do not need to be
will lower my cholesterol. eliminated (B) to lower cholesterol, but should be restricted to lean cuts of red
B) I need to avoid eating proteins, including red meat. meat and smaller portions (2-ounce servings). The low density lipoproteins (D)
C) I will limit my intake of beef to 4 ounces per week. need to decrease rather than increase
D) My blood level of low density lipoproteins needs to
increase.
Examination of a client complaining of itching on his right B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter
arm reveals a rash made up of multiple flat areas of
redness ranging from pinpoint to 0.5 cm in diameter. How Macules are localized flat skin discolorations less than 1 cm in diameter. However,
should the nurse record this finding? when recording such a finding the nurse should describe the appearance (B)
rather than simply naming the condition. (A) identifies vesicles -- fluid filled
A) Multiple vesicular areas surrounded by redness, blisters -- an incorrect description given the symptoms listed. (C) identifies
ranging in size from 1 mm to 0.5 cm. papules -- solid elevated lesions, again not correctly identifying the symptoms.
B) Localized red rash comprised of flat areas, pinpoint to (D) identifies petechiae -- pinpoint red to purple skin discolorations that do not
0.5 cm in diameter. itch, again an incorrect identification
C) Several areas of red, papular lesions from pinpoint to
0.5 cm in size.
D) Localized petechial areas, ranging in size from
pinpoint to 0.5 cm in diameter.
, A client who is 5' 5" tall and weighs 200 pounds is A) What is your daily calorie consumption?
scheduled for surgery the next day. What question is
most important for the nurse to include during the Vitamin and mineral supplements (B) may impact medications used during the
preoperative assessment? 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
A) What is your daily calorie consumption? clear liquid diet (D), rather than the client's preference
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?
The nurse is performing nasotracheal suctioning. After D) Re-oxygenate the client before attempting to suction again
suctioning the client's trachea for fifteen seconds, large
amounts of thick yellow secretions return. What action Suctioning should not be continued for longer than ten to fifteen seconds, since
should the nurse implement next? the client's oxygenation is compromised during this time (D). (A, B, and C) may be
performed after the client is re-oxygenated and additional suctioning is
A) Encourage the client to cough to help loosen performed.
secretions.
B) Advise the client to increase the intake of oral fluids.
C) Rotate the suction catheter to obtain any remaining
secretions.
D) Re-oxygenate the client before attempting to suction
again.
A hospitalized male client is receiving nasogastric tube C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from
feedings via a small-bore tube and a continuous pump the tube
infusion. He reports that he had a bad bout of severe
coughing a few minutes ago, but feels fine now. What Coughing, vomiting, and suctioning can precipitate displacement of the tip of the
action is best for the nurse to take? small bore feeding tube upward into the esophagus, placing the client at
increased risk for aspiration. Checking the sample of fluid withdrawn from the
A) Record the coughing incident. No further action is tube (after clearing the tube with 30 ml of air) for acidic (stomach) or alkaline
required at this time. (intestine) values is a more sensitive method for these tubes, and the nurse should
B) Stop the feeding, explain to the family why it is being assess tube placement in this way prior to taking any other action (C). (A and B)
stopped, and notify the healthcare provider. are not indicated. The auscultating method (D) has been found to be unreliable
C) After clearing the tube with 30 ml of air, check the pH for small-bore feeding tubes.
of fluid withdrawn from the tube.
D) Inject 30 ml of air into the tube while auscultating the
epigastrium for gurgling.
A female client with a nasogastric tube attached to low B) Reposition the client on her side
suction states that she is nauseated. The nurse assesses
that there has been no drainage through the nasogastric The immediate priority is to determine if the tube is functioning correctly, which
tube in the last two hours. What action should the nurse would then relieve the client's nausea. The least invasive intervention, (B), should
take first? 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
A) Irrigate the nasogastric tube with sterile normal saline. antiemetic (D).
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.
