Hesi Fundamentals 2019/20
Exam Questions
,Hesi Fundamentals 2019
Exam Questions
HESI FUNDAMENTALS 2019 EXAM
1. The home health nurse visits an elderly female client who had a brain
attack three months ago and is now able to ambulate with the
assistance of a quad cane. Which assessment finding has the greatest
implications for this client's care?
• The husband, who is the caregiver, begins to weep when the nurse asks
how he is doing.
• The client tells the nurse that she does not have much of an appetite
today.
• The nurse notes that there are numerous scatter rugs throughout the
house. Correct
• The client's pulse rate is 10 beats higher than it was at the last visit one
week ago. Scatter rugs (C) pose a safety hazard because the client can trip
on them when ambulating, so this finding has the greatest significance in
planning this client's care. Psychological support of the caregiver (A) is a
less acute need than that of client safety. The nurse needs to obtain more
information about (B), but this is not a safety issue. (D) is not a significant
increase, and additional assessment might provide information about the
reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a client. The nurse
should stop the procedure and take corrective action if which client
reaction is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the
anal
sphincter, which should be stopped if the client experiences a vagal response,
such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure.
3. The nurse is providing passive range of motion (ROM) exercises to
the hip and knee for a client who is unconscious. After supporting the
client's knee with one hand, what action should the nurse take next?
• Raise the bed to a comfortable working level.
, • Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct
Passive ROM exercise for the hip and knee is provided by supporting the
joints of the
knee and ankle (D) and gently moving the limb in a slow, smooth, firm but
gentle manner. (A) should be done before the exercises are begun to
prevent injury to the nurse and client. (B) is carried out after both joints are
supported. After the knee is bent, then the knee is moved toward the chest
to the point of resistance (C) two or three times.
4. A client who has moderate, persistent, chronic neuropathic pain due to
diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin,
Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief
ladder is prescribed, which drug protocol should be implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin
(Neurontin), an antiseizure medication, may be used at any step for anxiety
and pain management, so (A) should be implemented. Nonopiod analgesics,
such as ibuprofen
(A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics
(D), and to maintain freedom from pain, drugs should be given around the
clock rather than by the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling urinary
catheter using an open technique. What action should the nurse
take after applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe. Correct
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution.
To irrigate an indwelling urinary catheter, the nurse should first apply gloves,
then draw
up the irrigating solution into the syringe (B). The syringe is then attached
to the catheter and the fluid instilled, using aseptic technique (D). Once the
irrigating solution is instilled, the client's catheter should be secured to the
drainage tubing (C). The urinary drainage bag can be emptied (A) whenever
intake and output measurement is indicated, and the instilled irrigating fluid
can be subtracted from the output at that time.
Exam Questions
,Hesi Fundamentals 2019
Exam Questions
HESI FUNDAMENTALS 2019 EXAM
1. The home health nurse visits an elderly female client who had a brain
attack three months ago and is now able to ambulate with the
assistance of a quad cane. Which assessment finding has the greatest
implications for this client's care?
• The husband, who is the caregiver, begins to weep when the nurse asks
how he is doing.
• The client tells the nurse that she does not have much of an appetite
today.
• The nurse notes that there are numerous scatter rugs throughout the
house. Correct
• The client's pulse rate is 10 beats higher than it was at the last visit one
week ago. Scatter rugs (C) pose a safety hazard because the client can trip
on them when ambulating, so this finding has the greatest significance in
planning this client's care. Psychological support of the caregiver (A) is a
less acute need than that of client safety. The nurse needs to obtain more
information about (B), but this is not a safety issue. (D) is not a significant
increase, and additional assessment might provide information about the
reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a client. The nurse
should stop the procedure and take corrective action if which client
reaction is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct
• Respiratory rate increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the
anal
sphincter, which should be stopped if the client experiences a vagal response,
such as bradycardia (B). (A, C, and D) do not warrant stopping the procedure.
3. The nurse is providing passive range of motion (ROM) exercises to
the hip and knee for a client who is unconscious. After supporting the
client's knee with one hand, what action should the nurse take next?
• Raise the bed to a comfortable working level.
, • Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct
Passive ROM exercise for the hip and knee is provided by supporting the
joints of the
knee and ankle (D) and gently moving the limb in a slow, smooth, firm but
gentle manner. (A) should be done before the exercises are begun to
prevent injury to the nurse and client. (B) is carried out after both joints are
supported. After the knee is bent, then the knee is moved toward the chest
to the point of resistance (C) two or three times.
4. A client who has moderate, persistent, chronic neuropathic pain due to
diabetic neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin,
Advil) daily. If Step 2 of the World Health Organization (WHO) pain relief
ladder is prescribed, which drug protocol should be implemented?
• Continue gabapentin. Correct
• Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as
gabapentin
(Neurontin), an antiseizure medication, may be used at any step for anxiety
and pain management, so (A) should be implemented. Nonopiod analgesics,
such as ibuprofen
(A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics
(D), and to maintain freedom from pain, drugs should be given around the
clock rather than by the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling urinary
catheter using an open technique. What action should the nurse
take after applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe. Correct
• Secure the client's catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution.
To irrigate an indwelling urinary catheter, the nurse should first apply gloves,
then draw
up the irrigating solution into the syringe (B). The syringe is then attached
to the catheter and the fluid instilled, using aseptic technique (D). Once the
irrigating solution is instilled, the client's catheter should be secured to the
drainage tubing (C). The urinary drainage bag can be emptied (A) whenever
intake and output measurement is indicated, and the instilled irrigating fluid
can be subtracted from the output at that time.
