HESI FUNDAMENTALS PRACTICE EXAM QUESTION
CORRECTLY ANSWERED
1.The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin.: Observe the
appearance of the skin under the ice pack (The first action taken by the
nurse should be to assess the skin for any possible thermal injury. If no
injury to the skin has occurred, the nurse can take the other actions.)
2.The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor of 60
gtt/mL, how many drops per minute should the client receive?: 124 gtt/min
,3.The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/
30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration
set. The nurse plans to set the flow rate at how many gtt/min?: 83 gtt/min
4.Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube?: Examining a chest x-ray obtained after the
tubing was inserted
5.Three days following a surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the nurse that it is much bigger than he expected.
What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appear- ance in
time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure.: B. Instruct the client that the stoma will become smaller when
,the initial swelling diminishes (Postoperative swelling causes
enlargement of the stoma.
The nurse can teach the client that the stoma will become smaller when
swelling is diminished (B). This will help reduce the client's anxiety and
promote acceptance of the colostomy. (A) does not provide helpful
teaching or support. (C) is a useful action, and may be taken after the
nurse provides pertinent teaching. The client is not yet demonstrating
readiness to learn colostomy care. (D)
6.A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the nasogastric
tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.: B. Reposition the
client on her side. (The immediate priority is to determine if the tube is
functioning correctly, which would then relieve the client's nausea. The
least invasive interven- tion (B) should be attempted first, followed by
, (A and C), unless either of these interventions is contraindicated. If
these measures are unsuccessful, the client may require an antiemetic
(D))
7.A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. He reports that he had a bad bout of severe coughing
a few minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.: C.
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn
from the tube.
8.A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
CORRECTLY ANSWERED
1.The nurse observes that a male client has removed the covering from an ice park
applied to his knee. What action should the nurse take first?
A. Observe the appearance of the skin under the ice pack.
B. Instruct the client regarding the need for the covering.
C. Reapply the covering after filling with fresh ice.
D. Ask the client how long the ice was applied to the skin.: Observe the
appearance of the skin under the ice pack (The first action taken by the
nurse should be to assess the skin for any possible thermal injury. If no
injury to the skin has occurred, the nurse can take the other actions.)
2.The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the
solution at a rate of 5 mcg/kg/min to a client weighting 182 lbs. Using a drip factor of 60
gtt/mL, how many drops per minute should the client receive?: 124 gtt/min
,3.The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/
30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound
infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration
set. The nurse plans to set the flow rate at how many gtt/min?: 83 gtt/min
4.Which assessment data provides the most accurate determination of proper
placement of a nasogastric tube?: Examining a chest x-ray obtained after the
tubing was inserted
5.Three days following a surgery, a male client observes his colostomy for the first time.
He becomes quite upset and tells the nurse that it is much bigger than he expected.
What is the best response by the nurse?
A. Reassure the client that he will become accustomed to the stoma appear- ance in
time.
B. Instruct the client that the stoma will become much smaller when the initial swelling
diminishes.
C. Offer to contact a member of the local ostomy support group to help him with his
concerns.
D. Encourage the client to handle the stoma equipment to gain confidence with the
procedure.: B. Instruct the client that the stoma will become smaller when
,the initial swelling diminishes (Postoperative swelling causes
enlargement of the stoma.
The nurse can teach the client that the stoma will become smaller when
swelling is diminished (B). This will help reduce the client's anxiety and
promote acceptance of the colostomy. (A) does not provide helpful
teaching or support. (C) is a useful action, and may be taken after the
nurse provides pertinent teaching. The client is not yet demonstrating
readiness to learn colostomy care. (D)
6.A female client with a nasogastric tube attached to low suction states that she is
nauseated. The nurse assesses that there has been no drainage through the nasogastric
tube in the last two hours. What action should the nurse take first?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.: B. Reposition the
client on her side. (The immediate priority is to determine if the tube is
functioning correctly, which would then relieve the client's nausea. The
least invasive interven- tion (B) should be attempted first, followed by
, (A and C), unless either of these interventions is contraindicated. If
these measures are unsuccessful, the client may require an antiemetic
(D))
7.A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube
and a continuous pump infusion. He reports that he had a bad bout of severe coughing
a few minutes ago, but feels fine now. What action is best for the nurse to take?
A. Record the coughing incident. No further action is required at this time.
B. Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
D. Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.: C.
After clearing the tube with 30 ml of air, check the pH of fluid withdrawn
from the tube.
8.A male client tells the nurse that he does not know where he is or what year it is.
What data should the nurse document that is most accurate?
A. demonstrates loss of remote memory
B. exhibits expressive dysphasia
C. has a diminished attention span
