HESI Fundamentals (NCLEX), well
explained 2023/2024.
An adult is now alert and oriented following abdominal surgery. What position is most appropriate for
the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's - answersA
This position allows for greater thoracic expansion and puts less pressure on the suture line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload - answersB
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which action is least
appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day - answersC
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair. How should the
nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
,d. Facing the bed in the left side of the bed - answersA
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client?
a. Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position - answersA
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
a. Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV - answersB
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during tracheal
suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning - answersB--To prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most appropriate for
the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift - answersB
, Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a tracheostomy tube,
the client starts to cough. What is the best action for the nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions - answersD
During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal walls and
creates a pulling sensation. What is the best action for the nurse to take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper - answersA
Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the area when it cools
down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing - answersA
The day after surgery in which a colostomy was performed, the client says "I know the doctor did not
really do a colostomy". The nurse understands that the client is in an early stage of adjustment to the
diagnosis or surgery, with nursing action is indicated at this time?
a. Agree with the client until he is ready to accept the colostomy
b. Say "It must be difficult to have this kind of surgery"
c. Force the client to look at his colostomy
d. Ask the surgeon to explain the surgery to the client - answersB
explained 2023/2024.
An adult is now alert and oriented following abdominal surgery. What position is most appropriate for
the client?
A. Semi-Fowler's
B. Prone
C. Supine
D. Sim's - answersA
This position allows for greater thoracic expansion and puts less pressure on the suture line
Following a craniotomy, the nurse positioned a client in low fowler's for which reason?
A. To promote comfort
B. To promote drainage from operation site
C. To promote thoracic expansion
D. To prevent circulatory overload - answersB
The nurse is caring for a woman who had a CVA and has right-sided hemiplegia. Which action is least
appropriate?
a. Performing ROM exercise when bathing her
b. Changing her position every two hours
c. Suctioning the client supine and pulling the bed sheets tightly across her feet
d. Placing her in the prone position for one hour three times a day - answersC
The sheets should not be drawn tightly across the feet as this may cause foot drop
The nurse is to help their client with right-sided hemiplegia get up into the wheelchair. How should the
nurse place the wheelchair?
a. On the left side of the bed facing the foot of the bed
b. On the right side of the bed facing the head of the bed
c. Perpendicular to the bed on the right side
,d. Facing the bed in the left side of the bed - answersA
The client can then stand on the unaffected foot and pivot to sit down
When caring for a client in hemorrhagic shock, how should the nurse position the client?
a. Flat in bed with legs elevated
b. Flat in bed
c. Trendelenburg position
d. Semi-Fowler's position - answersA
Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?
a. Shave the neck
b. Establish a means of communication
c. Insert a Foley catheter
d. Start an IV - answersB
Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during tracheal
suctioning?
a. Using a lubricant such as petroleum jelly
b. Administering 100% oxygen before and after suctioning
c. Making sure that the suction catheter is open or on during insertion
d. Assisting the client to assume a supine position during suctioning - answersB--To prevent hypoxia
Mr. Landon is to have a tracheostomy performed. Which of the following actions is most appropriate for
the nurse to take when suctioning the tracheostomy?
a. Use sterile tube each time and suction for 30 seconds
b. Use sterile technique and turn the suction off as the catheter is introduced
c. Use clean technique and suction for 10 seconds
d. Discard the catheter at the end of every shift - answersB
, Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a tracheostomy tube,
the client starts to cough. What is the best action for the nurse to take?
a. Suction deeper to pick up secretions
b. Gently withdraw suction tubing to allow suction or coughing out of mucous
c. Remove the suction as quickly as possible
d. Put the suction in and out several times to pick up secretions - answersD
During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal walls and
creates a pulling sensation. What is the best action for the nurse to take?
a. Release the suction by opening the vent
b. Continue suctioning to remove obstruction
c. Increase the pressure
d. Suction deeper - answersA
Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
a. Use sterile technique when applying the dressing
b. Leave the compresses on the area continuously, pouring warm solution on the area when it cools
down
c. Alternate warm compressed with cold ones
d. Apply wet dressing, cover with dry dressing - answersA
The day after surgery in which a colostomy was performed, the client says "I know the doctor did not
really do a colostomy". The nurse understands that the client is in an early stage of adjustment to the
diagnosis or surgery, with nursing action is indicated at this time?
a. Agree with the client until he is ready to accept the colostomy
b. Say "It must be difficult to have this kind of surgery"
c. Force the client to look at his colostomy
d. Ask the surgeon to explain the surgery to the client - answersB
