ASN 120 FUNDAMENTALS HESI
A nurse observes that a male client has removed the covering from an ice pack 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)A. observe the appearance of the
skin under the ice pack
The first action by the nurse should be to access the skin for any possible thermal injury.
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 weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per
minute should the client receive?
A. 31 gtt/min.
B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. - (answer)D. 124gtt/min
The healthcare provider prescribes an IV infusion of 1,000ml of LR with 30 units of Pitocin to run in over
4 hours for a client who has just delivered a 10lb infant by C 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?
A. 42 gtt/min
B. 83 gtt/min
C. 125 gtt/min
D. 250 gtt/min - (answer)B. 83 gtt/min
Which assessment data provides the most accurate determination of proper placement of an NG tube?
,A. aspirating gastric contents to assure a pH value of 4 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 to ensure that the correct length was inserted - (answer)C. examining
the chest x-ray obtained after the tubing was inserted
The best indicator the the tubing is placed properly is by x-ray
Three days following 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 be accustomed to the stoma appearance in time
B. instruct the client that the stoma will become 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 the swelling is diminished.
A female client with an NG tube attached to low suction states that she is nauseated. The nurse assesses
the there has been no drainage through the tube in the last 2 hours. Which action should the nurse
take?
A. irrigate the NG tube with NS
B. Reposition the client on her side
C. advance the NG tube an additional 5cm
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 properly, which would then relieve the
patient's nausea. The least invasive intervention should be attempted first.
A hospitalized male client is receiving an NG 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 mins 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
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding
tube upward into the esophagus, placing the client at increased risk of aspiration. Checking the sample
of fluid withdrawn from the tube for acidic or alkaline values is more sensitive method for these tubes,
and the nurse should assess the tube placement in this way prior to taking any other action.
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
A client with CKD selects scrambled eggs for his breakfast. Which 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
A nurse observes that a male client has removed the covering from an ice pack 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)A. observe the appearance of the
skin under the ice pack
The first action by the nurse should be to access the skin for any possible thermal injury.
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 weighing 182 pounds. Using a drip factor of 60 gtt/ml, how many drops per
minute should the client receive?
A. 31 gtt/min.
B. 62 gtt/min.
C. 93 gtt/min.
D. 124 gtt/min. - (answer)D. 124gtt/min
The healthcare provider prescribes an IV infusion of 1,000ml of LR with 30 units of Pitocin to run in over
4 hours for a client who has just delivered a 10lb infant by C 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?
A. 42 gtt/min
B. 83 gtt/min
C. 125 gtt/min
D. 250 gtt/min - (answer)B. 83 gtt/min
Which assessment data provides the most accurate determination of proper placement of an NG tube?
,A. aspirating gastric contents to assure a pH value of 4 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 to ensure that the correct length was inserted - (answer)C. examining
the chest x-ray obtained after the tubing was inserted
The best indicator the the tubing is placed properly is by x-ray
Three days following 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 be accustomed to the stoma appearance in time
B. instruct the client that the stoma will become 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 the swelling is diminished.
A female client with an NG tube attached to low suction states that she is nauseated. The nurse assesses
the there has been no drainage through the tube in the last 2 hours. Which action should the nurse
take?
A. irrigate the NG tube with NS
B. Reposition the client on her side
C. advance the NG tube an additional 5cm
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 properly, which would then relieve the
patient's nausea. The least invasive intervention should be attempted first.
A hospitalized male client is receiving an NG 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 mins 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
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small bore feeding
tube upward into the esophagus, placing the client at increased risk of aspiration. Checking the sample
of fluid withdrawn from the tube for acidic or alkaline values is more sensitive method for these tubes,
and the nurse should assess the tube placement in this way prior to taking any other action.
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
A client with CKD selects scrambled eggs for his breakfast. Which 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
