ALL HESI FUNDAMENTALS EXAM SPRING
2023/2024.TEST
BANK UPDATED Assured Correct Answers TOP
TARGET ACADEMIC
1. 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. - 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
2. 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.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - 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
3. 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. - 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 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
4. 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. - 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). Correct Answer: A
5. 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. - 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
6. 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
morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. -
To ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are
not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D
7. While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm
,above and below the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion. - The wife isperforming
the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The
joint that is being exercised should be uncovered (B) while the rest of the body should
remain covered for warmth and privacy. (C and D) do not provide adequate
support to the joint while still allowing for joint movement. Correct Answer: A
8. What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is
used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. -
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged,
could be life-threatening. Superficial veins are often very easy (A) to find in the feet
and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than
handling an arm or hand. Even if the nurse did believe moving a cannulated leg was
more difficult, this is not the most important reason for using the upper extremities.
Pain (D) is not a consideration.
Correct Answer: B
9. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - Themost
important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed
(A). Though (C and D) are likely indicated, these actions do not have the priority of (B).
Correct Answer: B
10. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB.
The preparation arrives from the pharmacy diluted in 50 ml of
0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how
many ml/hr should the infusion pump be set to deliver the secondary infusion? - The
infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60
min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150
, 11. Twenty minutes after beginning a heat application, the client states that the heating
pad no longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body's receptors adapt over time as they are exposed to heat. - (D)describes
thermal adaptation, which occurs 20 to 30 minutes after heat application.
(A and B)
provide false information. (C) is not based on a knowledge of physiology and is an unsafe
action that may harm the client. Correct Answer: D
12. The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low density lipoproteins needs to increase. - Limiting saturated fat
from animal food sources to no more than 4 ounces per week (C) is an important diet
modification for lowering cholesterol. To be effective in reducing cholesterol, the client
should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and
all proteins do not need to be eliminated (B) to lower cholesterol, but should be
restricted to lean cuts of red meat and smaller portions (2-ounce servings). The
low density lipoproteins (D) need to decrease rather than increase. Correct
Answer: C
13. The UAPs working on a chronic neuro unit ask the nurse to help them determine the
safest way to transfer an elderly client with left-sided weakness from the bed to the
chair. What method describes the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side beforemoving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the clienton the right
foot. - (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of
transfer and include the use of poor body mechanics by the caregiver. Correct
Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile
soap.
C. Reposition in a Sim's position with the client's weight on the anterior
ilium.
2023/2024.TEST
BANK UPDATED Assured Correct Answers TOP
TARGET ACADEMIC
1. 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. - 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
2. 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.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water. - 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
3. 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. - 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 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
4. 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. - 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). Correct Answer: A
5. 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. - 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
6. 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
morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. -
To ensure that a therapeutic level of medication is maintained, the nurse should
administer the missed dose as soon as possible, and revise the administration schedule
accordingly to prevent dangerously increasing the level of the medication in the
bloodstream (D). The nurse should document the reason for the late dose, but (A and C) are
not warranted. (B) could result in increased blood levels of the drug. Correct Answer: D
7. While instructing a male client's wife in the performance of passive range-of-motion
exercises to his contracted shoulder, the nurse observes that she is holding his arm
,above and below the elbow. What nursing action should the nurse implement?
A. Acknowledge that she is supporting the arm correctly.
B. Encourage her to keep the joint covered to maintain warmth.
C. Reinforce the need to grip directly under the joint for better support.
D. Instruct her to grip directly over the joint for better motion. - The wife isperforming
the passive ROM correctly, therefore the nurse should acknowledge this fact (A). The
joint that is being exercised should be uncovered (B) while the rest of the body should
remain covered for warmth and privacy. (C and D) do not provide adequate
support to the joint while still allowing for joint movement. Correct Answer: A
8. What is the most important reason for starting intravenous infusions in the upper
extremities rather than the lower extremities of adults?
A. It is more difficult to find a superficial vein in the feet and ankles.
B. A decreased flow rate could result in the formation of a thrombosis.
C. A cannulated extremity is more difficult to move when the leg or foot is
used.
D. Veins are located deep in the feet and ankles, resulting in a more painful procedure. -
Venous return is usually better in the upper extremities. Cannulation of the veins in the
lower extremities increases the risk of thrombus formation (B) which, if dislodged,
could be life-threatening. Superficial veins are often very easy (A) to find in the feet
and legs. Handling a leg or foot with an IV (C) is probably not any more difficult than
handling an arm or hand. Even if the nurse did believe moving a cannulated leg was
more difficult, this is not the most important reason for using the upper extremities.
Pain (D) is not a consideration.
Correct Answer: B
9. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood
pressure with a cuff that is too small, but the blood pressure reading obtained is within
the client's usual range. What action is most important for the nurse to implement?
A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure. - Themost
important action is to ensure that an accurate BP reading is obtained. The nurse should
reassess the BP with the correct size cuff (B). Reassessment should not be postponed
(A). Though (C and D) are likely indicated, these actions do not have the priority of (B).
Correct Answer: B
10. A client is to receive cimetidine (Tagamet) 300 mg q6h IVPB.
The preparation arrives from the pharmacy diluted in 50 ml of
0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how
many ml/hr should the infusion pump be set to deliver the secondary infusion? - The
infusion rate is calculated as a ratio proportion problem, i.e., 50 ml/ 20 min : x ml/ 60
min. Multiply extremes and means 50 × 60 /20x 1= 300/20=150 Correct Answer: 150
, 11. Twenty minutes after beginning a heat application, the client states that the heating
pad no longer feels warm enough. What is the best response by the nurse?
A. That means you have derived the maximum benefit, and the heat can be removed.
B. Your blood vessels are becoming dilated and removing the heat from the site.
C. We will increase the temperature 5 degrees when the pad no longer feels warm.
D. The body's receptors adapt over time as they are exposed to heat. - (D)describes
thermal adaptation, which occurs 20 to 30 minutes after heat application.
(A and B)
provide false information. (C) is not based on a knowledge of physiology and is an unsafe
action that may harm the client. Correct Answer: D
12. The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A. If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B. I need to avoid eating proteins, including red meat.
C. I will limit my intake of beef to 4 ounces per week.
D. My blood level of low density lipoproteins needs to increase. - Limiting saturated fat
from animal food sources to no more than 4 ounces per week (C) is an important diet
modification for lowering cholesterol. To be effective in reducing cholesterol, the client
should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and
all proteins do not need to be eliminated (B) to lower cholesterol, but should be
restricted to lean cuts of red meat and smaller portions (2-ounce servings). The
low density lipoproteins (D) need to decrease rather than increase. Correct
Answer: C
13. The UAPs working on a chronic neuro unit ask the nurse to help them determine the
safest way to transfer an elderly client with left-sided weakness from the bed to the
chair. What method describes the correct transfer procedure for this client?
A. Place the chair at a right angle to the bed on the client's left side beforemoving.
B. Assist the client to a standing position, then place the right hand on the
armrest.
C. Have the client place the left foot next to the chair and pivot to the left before sitting.
D. Move the chair parallel to the right side of the bed, and stand the clienton the right
foot. - (D) uses the client's stronger side, the right side, for weight-bearing during the
transfer, and is the safest approach to take. (A, B, and C) are unsafe methods of
transfer and include the use of poor body mechanics by the caregiver. Correct
Answer: D
An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to
administering a soap suds enema. Which instruction should the nurse provide the UAP?
A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile
soap.
C. Reposition in a Sim's position with the client's weight on the anterior
ilium.
