HESI RN Fundamentals
1. 1.ID: 311236316
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. Correct
To avoid shearing forces when repositioning, the client should be lifted gently across a
surface (D). Reddened areas should not be massaged (A) since this may increase the damage
to already traumatized skin. To control pain and muscle spasms, active range of motion (B)
may be limited on the affected leg. The position described in (C) is contraindicated for a
client with a fractured left hip.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 311259558
The nurse is administering medications through a nasogastric tube (NGT) which is connected
to suction. After ensuring correct tube placement, what action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water. Correct
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each medication administered (B).
Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C
and D) may be implemented only after the tubing has been flushed.
, Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 311201102
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the nurse
implement?
A. Give an around-the-clock schedule for administration of analgesics. Correct
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.
The most effective management of pain is achieved using an around-the-clock schedule that
provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are
less effective if pain persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing comfort is a priority for the client
who is dying, but sedation that impairs the client's ability to interact and experience the time
before life ends should be minimized (C). Offering a medication-free period allows the
serum drug level to fall, which is not an effective method to manage chronic pain (D).
Awarded 0.0 points out of 1.0 possible points.
4. 4.ID: 311212896
When assessing a client with wrist restraints, the nurse observes that the fingers on the right
hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint. Correct
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
, The priority nursing action is to restore circulation by loosening the restraint (A), because
blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation
of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to
mechanical compression (the restraints).
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 311205664
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant. Correct
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are
all conditions that require protein, but do not have the increased metabolic protein demands
of lactation.
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 311269346
A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at
1300. What is the best intervention for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
, D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct
To ensure that a therapeutic level of medication is maintained, the nurse should administer
the missed dose as soon as possible, and revise the administration schedule accordingly to
prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse
should document the reason for the late dose, but (A and C) are not warranted. (B) could
result in increased blood levels of the drug.
Awarded 0.0 points out of 1.0 possible points.
7. 7.ID: 311199864
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above and
below the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly. Correct
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the nurse should acknowledge
this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the
body should remain covered for warmth and privacy. (C and D) do not provide adequate
support to the joint while still allowing for joint movement.
Awarded 0.0 points out of 1.0 possible points.
8. 8.ID: 311223480
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
1. 1.ID: 311236316
An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is
essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position. Correct
To avoid shearing forces when repositioning, the client should be lifted gently across a
surface (D). Reddened areas should not be massaged (A) since this may increase the damage
to already traumatized skin. To control pain and muscle spasms, active range of motion (B)
may be limited on the affected leg. The position described in (C) is contraindicated for a
client with a fractured left hip.
Awarded 0.0 points out of 1.0 possible points.
2. 2.ID: 311259558
The nurse is administering medications through a nasogastric tube (NGT) which is connected
to suction. After ensuring correct tube placement, what action should the nurse take next?
A. Clamp the tube for 20 minutes.
B. Flush the tube with water. Correct
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
The NGT should be flushed before, after and in between each medication administered (B).
Once all medications are administered, the NGT should be clamped for 20 minutes (A). (C
and D) may be implemented only after the tubing has been flushed.
, Awarded 0.0 points out of 1.0 possible points.
3. 3.ID: 311201102
A client who is in hospice care complains of increasing amounts of pain. The healthcare
provider prescribes an analgesic every four hours as needed. Which action should the nurse
implement?
A. Give an around-the-clock schedule for administration of analgesics. Correct
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.
The most effective management of pain is achieved using an around-the-clock schedule that
provides analgesic medications on a regular basis (A) and in a timely manner. Analgesics are
less effective if pain persists until it is severe, so an analgesic medication should be
administered before the client's pain peaks (B). Providing comfort is a priority for the client
who is dying, but sedation that impairs the client's ability to interact and experience the time
before life ends should be minimized (C). Offering a medication-free period allows the
serum drug level to fall, which is not an effective method to manage chronic pain (D).
Awarded 0.0 points out of 1.0 possible points.
4. 4.ID: 311212896
When assessing a client with wrist restraints, the nurse observes that the fingers on the right
hand are blue. What action should the nurse implement first?
A. Loosen the right wrist restraint. Correct
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
, The priority nursing action is to restore circulation by loosening the restraint (A), because
blue fingers (cyanosis) indicates decreased circulation. (C and D) are also important nursing
interventions, but do not have the priority of (A). Pulse oximetry (B) measures the saturation
of hemoglobin with oxygen and is not indicated in situations where the cyanosis is related to
mechanical compression (the restraints).
Awarded 0.0 points out of 1.0 possible points.
5. 5.ID: 311205664
The nurse is assessing the nutritional status of several clients. Which client has the greatest
nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant. Correct
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer.
A lactating woman (B) has the greatest need for additional protein intake. (A, C, and D) are
all conditions that require protein, but do not have the increased metabolic protein demands
of lactation.
Awarded 0.0 points out of 1.0 possible points.
6. 6.ID: 311269346
A client is in the radiology department at 0900 when the prescription levofloxacin
(Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at
1300. What is the best intervention for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
, D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct
To ensure that a therapeutic level of medication is maintained, the nurse should administer
the missed dose as soon as possible, and revise the administration schedule accordingly to
prevent dangerously increasing the level of the medication in the bloodstream (D). The nurse
should document the reason for the late dose, but (A and C) are not warranted. (B) could
result in increased blood levels of the drug.
Awarded 0.0 points out of 1.0 possible points.
7. 7.ID: 311199864
While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm above and
below the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly. Correct
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion.
The wife is performing the passive ROM correctly, therefore the nurse should acknowledge
this fact (A). The joint that is being exercised should be uncovered (B) while the rest of the
body should remain covered for warmth and privacy. (C and D) do not provide adequate
support to the joint while still allowing for joint movement.
Awarded 0.0 points out of 1.0 possible points.
8. 8.ID: 311223480
What is the most important reason for starting intravenous infusions in the upper extremities
rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
