HESI FUNDAMENTALS PRACTICE QUESTIONS AND
ANSWERS WITH RATIONALES COMPLETE A+ GUIDE
2023
Fundamentals B Quiz. (Hesi)
• The home health nurse visits an elderly female client who had a brain attack three months ago
and isnow 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.).
• The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure
andtake 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
shouldbe stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D)
do not warrant stopping the procedure.
• The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client
who isunconscious. 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.
• 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 3include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around
the clockrather than by the client s PRN requests.
• The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
Whataction 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
irrigatingsolution 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 tothe 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.
• Which client care requires the nurse to wear barrier gloves as required by the protocol for
StandardPrecautions?
, • Removing the empty food tray from a client with a urinary catheter.
• Washing and combing the hair of a client with a fractured leg in traction.
• Administering oral medications to a cooperative client with a wound infection.
• Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct
Possible contact with body secretions, excretions, or broken skin is an indication for wearing
barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B,
and C) do notrequire gloves.
• What action should the nurse implement to prevent the formation of a sacral ulcer for a client
who isimmobile?
• Maintain in a lateral position using protective wrist and vest devices.
• Position prone with a small pillow below the diaphragm. Correct
• Raise the head and knee gatch when lying in a supine position.
• Transfer into a wheelchair close to the nurse's station for observation.
The prone position (B) using a small pillow below the diaphragm maintains alignment and provides
the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is
not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in
bed, butit interferes with venous return from the legs and places pressure on the sacrum,
predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial
tuberosities and predisposes to a potential pressure point.
• What intervention should the nurse include in the plan of care for a client who is being treated
with anUnna's paste boot for leg ulcers due to chronic venous insufficiency?
• Check capillary refill of toes on lower extremity with Unna's paste boot. Correct
• Apply dressing to wound area before applying the Unna's paste boot.
• Wrap the leg from the knee down towards the foot.
• Remove the Unna's paste boot q8h to assess wound healing.
The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate
circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be
usedto cover both, but no bandage should be put under it (B). The Unna's paste boot should be
applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile
dressing, and should not be removed q8h. Weekly removal is reasonable (D).
• The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous
(IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the
alarm onthe infusion pump indicates an obstruction. What action should the nurse take first?
• Check for a blood return.
• Reposition the client's arm. Correct
• Remove the IV site dressing.
ANSWERS WITH RATIONALES COMPLETE A+ GUIDE
2023
Fundamentals B Quiz. (Hesi)
• The home health nurse visits an elderly female client who had a brain attack three months ago
and isnow 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.).
• The nurse is digitally removing a fecal impaction for a client. The nurse should stop the procedure
andtake 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
shouldbe stopped if the client experiences a vagal response, such as bradycardia (B). (A, C, and D)
do not warrant stopping the procedure.
• The nurse is providing passive range of motion (ROM) exercises to the hip and knee for a client
who isunconscious. 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.
• 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 3include opioid narcotics (D), and to maintain freedom from pain, drugs should be given around
the clockrather than by the client s PRN requests.
• The nurse is preparing to irrigate a client's indwelling urinary catheter using an open technique.
Whataction 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
irrigatingsolution 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 tothe 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.
• Which client care requires the nurse to wear barrier gloves as required by the protocol for
StandardPrecautions?
, • Removing the empty food tray from a client with a urinary catheter.
• Washing and combing the hair of a client with a fractured leg in traction.
• Administering oral medications to a cooperative client with a wound infection.
• Emptying the urinary catheter drainage bag for a client with Alzheimer's disease. Correct
Possible contact with body secretions, excretions, or broken skin is an indication for wearing
barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of gloves (D). (A, B,
and C) do notrequire gloves.
• What action should the nurse implement to prevent the formation of a sacral ulcer for a client
who isimmobile?
• Maintain in a lateral position using protective wrist and vest devices.
• Position prone with a small pillow below the diaphragm. Correct
• Raise the head and knee gatch when lying in a supine position.
• Transfer into a wheelchair close to the nurse's station for observation.
The prone position (B) using a small pillow below the diaphragm maintains alignment and provides
the best pressure relief over the sacral bony prominence. Using protective (restraining) devices (A) is
not indicated. Raising the head and bed gatch (C) may reduce shearing forces due to sliding down in
bed, butit interferes with venous return from the legs and places pressure on the sacrum,
predisposing to ulcer formation. Sitting in a wheelchair (D) places the body weight over the ischial
tuberosities and predisposes to a potential pressure point.
• What intervention should the nurse include in the plan of care for a client who is being treated
with anUnna's paste boot for leg ulcers due to chronic venous insufficiency?
• Check capillary refill of toes on lower extremity with Unna's paste boot. Correct
• Apply dressing to wound area before applying the Unna's paste boot.
• Wrap the leg from the knee down towards the foot.
• Remove the Unna's paste boot q8h to assess wound healing.
The Unna's paste boot becomes rigid after it dries, so it is important to check distally for adequate
circulation (A). Kerlix is often wrapped around the outside of the boot and an ace bandage may be
usedto cover both, but no bandage should be put under it (B). The Unna's paste boot should be
applied from the foot and wrapped towards the knee (C). The Unna's paste boot acts as a sterile
dressing, and should not be removed q8h. Weekly removal is reasonable (D).
• The nurse is administering an intermittent infusion of an antibiotic to a client whose intravenous
(IV) access is an antecubital saline lock. After the nurse opens the roller clamp on the IV tubing, the
alarm onthe infusion pump indicates an obstruction. What action should the nurse take first?
• Check for a blood return.
• Reposition the client's arm. Correct
• Remove the IV site dressing.
