2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
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
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
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.
,2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
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
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-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
,2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
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).
Correct Answer: A
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).
, 2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
Correct Answer: A
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
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
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
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
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
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.
,2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
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
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-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
,2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
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).
Correct Answer: A
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).
, 2023 HESI EXAM:CRITICAL THINKING
QUESTIONS WITH COMPLETE SOLUTIONS A+
PASS ASSUARED
Correct Answer: A
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
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
