HESI CRITICAL THINKING PRACTICE EXAM
QUESTIONS AND ANSWERS WITH EXPLANATIONS
(LATEST)
1. An elderly client with a fractured left hip is on strict bed rest. 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 ANSWER 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.
Correct Answer: D
2. 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.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
- CORRECT ANSWER 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.
Correct Answer: B
3. 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.
,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.
- CORRECT ANSWER The most effective management of pain is achieved using an
around-theclock 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 theclient'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 aneffective method to manage chronic pain (D).
Correct Answer: A
4. 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.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
- CORRECT ANSWER 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).
Correct Answer: A
5. 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.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - CORRECT ANSWER 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.
Correct Answer: B
6. 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 ANSWER 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.
Correct Answer: D
7. 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.
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.
- CORRECT ANSWER 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.
QUESTIONS AND ANSWERS WITH EXPLANATIONS
(LATEST)
1. An elderly client with a fractured left hip is on strict bed rest. 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 ANSWER 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.
Correct Answer: D
2. 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.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.
- CORRECT ANSWER 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.
Correct Answer: B
3. 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.
,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.
- CORRECT ANSWER The most effective management of pain is achieved using an
around-theclock 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 theclient'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 aneffective method to manage chronic pain (D).
Correct Answer: A
4. 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.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.
- CORRECT ANSWER 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).
Correct Answer: A
5. 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.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. - CORRECT ANSWER 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.
Correct Answer: B
6. 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 ANSWER 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.
Correct Answer: D
7. 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.
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.
- CORRECT ANSWER 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.
