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Additional HESI Fundamentals Recommended Sets
Exam Reviews Questions with 100% Original Verified
Solutions, A+ Grade, Latest update | Download.
The 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. - ANSWER-
Observe 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? - ANSWER-124 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? - ANSWER-83 gtt/min
Which assessment data provides the most accurate determination of
proper placement of a nasogastric tube? - ANSWER-Examining a chest
x-ray obtained after the tubing was inserted
,2|Page
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. - ANSWER-B. 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. -
ANSWER-B. 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))
,3|Page
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. - ANSWER-C. 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 - ANSWER-D. 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. - ANSWER-A. 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
, 4|Page
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-- -
ANSWER-Upper 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 - ANSWER-B. 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 - ANSWER-C.
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
Additional HESI Fundamentals Recommended Sets
Exam Reviews Questions with 100% Original Verified
Solutions, A+ Grade, Latest update | Download.
The 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. - ANSWER-
Observe 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? - ANSWER-124 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? - ANSWER-83 gtt/min
Which assessment data provides the most accurate determination of
proper placement of a nasogastric tube? - ANSWER-Examining a chest
x-ray obtained after the tubing was inserted
,2|Page
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. - ANSWER-B. 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. -
ANSWER-B. 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))
,3|Page
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. - ANSWER-C. 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 - ANSWER-D. 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. - ANSWER-A. 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
, 4|Page
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-- -
ANSWER-Upper 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 - ANSWER-B. 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 - ANSWER-C.
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
