HESI TEST BANK FUNDAMENTALS. 2024/2025 A+
GRADE REVISION MATERIAL. PREVIED AND UPDATED
WITH ANSWERS
1. The home health nurse visits an elderly female client who had
a brain attack three months ago and is now able to ambulate with
the assistance of the quad cane. Which assessment finding has the
greatest implications for this client’s care? The nurse notes that
there are numerous scatter rugs throughout the house. Scatter
rugs 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
2. The nurse is digitally removing a fecal impaction for a client.
The nurse should stop the procedure and take corrective action if
which client reaction is noted? Pulse rate decreases from 78 to 52
beats/min.
Parasympathetic reactions can occur as a result of digital stimulation
of the anal sphincter, which should be stopped if the client
experiences a vagal response, such as bradycardia
3. The nurse is providing passive range of motion exercises to
the hip and knee for a client who is unconscious. After
supporting the client's knee with one hand, what action should
the nurse take next? Cradle the client's heel.
Passive ROM exercise for the hip and knee is provided by supporting the
joints of the knee and ankle and gently moving the limb in a slow,
smooth, firm but gentle manner, followed by bending the knee and
moving it toward the chest as far as it will go. Bed should be raised to a
comfortable working level first
4. A client who has moderate, persistent, chronic neuropathic
pain due to diabetic neuropathy takes gabapentin (Neurontin)
and ibuprofen daily. If step 2 of the WHO pain relief ladder is
prescribed, which drug protocol should be implemented?
Continue gabapentin
*Step 1 drugs are nonopioid analgesics
1/8
, HESI TEST BANK FUNDAMENTALS. 2024/2025 A+
GRADE REVISION MATERIAL. PREVIED AND UPDATED
WITH ANSWERS
*Step 2 and 3 are narcotics and should be given around the clock
rather than by the clients PRN requests
5. The nurse is preparing to irrigate a client's indwelling
urinary catheter using an open technique. What action should the
nurse take after applying gloves? Draw up the irrigating solution
into the syringe.
To irrigate an indwelling urinary catheter, the nurse should first apply
gloves, then draw up the irrigating solution into the syringe. The syringe
is then attached to the catheter and the fluid instilled, using aseptic
technique. Once the irrigating solution is instilled, the client's catheter
should be secured to the drainage tubing. The urinary drainage bag can be
emptied whenever intake and output measurement are indicated, and the
instilled irrigating fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier gloves
as required by the protocol for standard precautions? Emptying
the urinary catheter drainage bag for a client with Alzheimer's
disease
*Possible contact with body secretions, excretions, or broken skin is
an indication for wearing barrier gloves. Emptying a urine drainage
bag requires the use of gloves. 7. What action should the nurse
implement to prevent the formation of a sacral ulcer for a client who
is immobile? Position prone with a small pillow below the diaphragm
*This maintains alignment and provides the best pressure relief over
the sacral bony prominence
8. What intervention should the nurse include in the plan of
care for a client who is being treated with an Unna's paste boot
for leg ulcers due to chronic venous insufficiency? Check
capillary refill of toes on lower extremity with Unna's paste boot
*It becomes rigid after it dries so it is important to check distally for
adequate circulation
2/8
GRADE REVISION MATERIAL. PREVIED AND UPDATED
WITH ANSWERS
1. The home health nurse visits an elderly female client who had
a brain attack three months ago and is now able to ambulate with
the assistance of the quad cane. Which assessment finding has the
greatest implications for this client’s care? The nurse notes that
there are numerous scatter rugs throughout the house. Scatter
rugs 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
2. The nurse is digitally removing a fecal impaction for a client.
The nurse should stop the procedure and take corrective action if
which client reaction is noted? Pulse rate decreases from 78 to 52
beats/min.
Parasympathetic reactions can occur as a result of digital stimulation
of the anal sphincter, which should be stopped if the client
experiences a vagal response, such as bradycardia
3. The nurse is providing passive range of motion exercises to
the hip and knee for a client who is unconscious. After
supporting the client's knee with one hand, what action should
the nurse take next? Cradle the client's heel.
Passive ROM exercise for the hip and knee is provided by supporting the
joints of the knee and ankle and gently moving the limb in a slow,
smooth, firm but gentle manner, followed by bending the knee and
moving it toward the chest as far as it will go. Bed should be raised to a
comfortable working level first
4. A client who has moderate, persistent, chronic neuropathic
pain due to diabetic neuropathy takes gabapentin (Neurontin)
and ibuprofen daily. If step 2 of the WHO pain relief ladder is
prescribed, which drug protocol should be implemented?
Continue gabapentin
*Step 1 drugs are nonopioid analgesics
1/8
, HESI TEST BANK FUNDAMENTALS. 2024/2025 A+
GRADE REVISION MATERIAL. PREVIED AND UPDATED
WITH ANSWERS
*Step 2 and 3 are narcotics and should be given around the clock
rather than by the clients PRN requests
5. The nurse is preparing to irrigate a client's indwelling
urinary catheter using an open technique. What action should the
nurse take after applying gloves? Draw up the irrigating solution
into the syringe.
To irrigate an indwelling urinary catheter, the nurse should first apply
gloves, then draw up the irrigating solution into the syringe. The syringe
is then attached to the catheter and the fluid instilled, using aseptic
technique. Once the irrigating solution is instilled, the client's catheter
should be secured to the drainage tubing. The urinary drainage bag can be
emptied whenever intake and output measurement are indicated, and the
instilled irrigating fluid can be subtracted from the output at that time.
6. Which client care requires the nurse to wear barrier gloves
as required by the protocol for standard precautions? Emptying
the urinary catheter drainage bag for a client with Alzheimer's
disease
*Possible contact with body secretions, excretions, or broken skin is
an indication for wearing barrier gloves. Emptying a urine drainage
bag requires the use of gloves. 7. What action should the nurse
implement to prevent the formation of a sacral ulcer for a client who
is immobile? Position prone with a small pillow below the diaphragm
*This maintains alignment and provides the best pressure relief over
the sacral bony prominence
8. What intervention should the nurse include in the plan of
care for a client who is being treated with an Unna's paste boot
for leg ulcers due to chronic venous insufficiency? Check
capillary refill of toes on lower extremity with Unna's paste boot
*It becomes rigid after it dries so it is important to check distally for
adequate circulation
2/8
