Fundamental HESI, Hesi Fundamentals, Hesi Fundamentals
Practice Test, UNIT 1: Foundations of Nursing Practice
Questions With Complete Solutions
"It shows the time needed for the SA node impulse to depolarize
the atria and travel through the AV node."
Explanation:
The PR interval is measured from the beginning of the P wave to
the beginning of the QRS complex and represents the time
needed for sinus node stimulation, atrial depolarization, and
conduction through the AV node before ventricular
depolarization. In a normal heart the impulses do not travel
backward. The PR interval does not include the time it take to
travel through the Purkinje fibers Correct Answers P-R interval
0.24 seconds
Explanation:
In adults, the normal range for the PR is 0.12 to 0.20 seconds. A
PR internal of 0.24 seconds would indicate a first-degree heart
block. Correct Answers Which PR interval presents a first-
degree heart block?
A 73-year-old female client had a hemiarthroplasty of the left
hip yesterday due to a fracture resulting from a fall. In reviewing
hip precautions with the client, which instruction should the
nurse include in this client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach
items on the floor.
B. Place a pillow between your knees while lying in bed to
prevent hip dislocation.
,C. It is safe to use a walker to get out of bed, but you need
assistance when walking.
D. Take pain medication 30 minutes after your physical therapy
sessions. Correct Answers The client's affected hip joint
following a hemiarthroplasty (partial hip replacement) is at risk
of dislocation for 6 months to a year following the procedure.
Hip precautions to prevent dislocation include placing a pillow
between the knees to maintain abduction of the hips (B). Clients
should be instructed to avoid bending at the waist (A), to seek
assistance for both standing and walking until they are stable on
a walker or cane (C), and to take pain medication 20 to 30
minutes prior to physical therapy sessions, rather than waiting
until the pain level is high after their therapy.
Correct Answer: B
A client asks about the purpose of a pulse oximeter. The nurse
explains that it is used to measure the:
1
Respiratory rate.
2
Amount of oxygen in the blood.
3
Percentage of hemoglobin-carrying oxygen.
4
Amount of carbon dioxide in the blood Correct Answers 3
The pulse oximeter measures the oxygen saturation of blood by
determining the percentage of hemoglobin-carrying oxygen. A
pulse oximeter does not interpret the amount of oxygen or
carbon dioxide carried in the blood, nor does it measure
respiratory rate.
,A client comes to the clinic complaining of a productive cough
with copious yellow sputum, fever, and chills for the past two
days. The first thing the nurse should do when caring for this
client is to:
1
Encourage fluids.
2
Administer oxygen.
3
Take the temperature.
4
Collect a sputum specimen Correct Answers 3
Baseline vital signs are extremely important; physical
assessment precedes diagnostic measures and intervention. This
is done after the health care provider makes a medical diagnosis;
this is not an independent function of the nurse. Encouraging
fluids might be done after it is determined whether a specimen
for blood gases is needed; this is not usually an independent
function of the nurse. Oxygen is administered independently by
the nurse only in an emergency situation. A sputum specimen
should be obtained after vital signs and before administration of
antibiotics.
A client has a pressure ulcer that is full thickness with necrosis
into the subcutaneous tissue down to the underlying fascia. The
nurse should document the assessment finding as which stage of
pressure ulcer?
1
Stage I
2
Stage II
, 3
Stage III
4
Unstageable Correct Answers 4
A pressure ulcer with necrotic tissue is unstageable. The necrotic
tissue must be removed before the wound can be staged. A stage
I pressure ulcer is defined as an area of persistent redness with
no break in skin integrity. A stage II pressure ulcer is a partial-
thickness wound with skin loss involving the epidermis, dermis,
or both; the ulcer is superficial and may present as an abrasion,
blister, or shallow crater. A stage III pressure ulcer involves full
thickness tissue loss with visible subcutaneous fat. Bone,
tendon, and muscle are not exposed.
A client has an anaphylactic reaction after receiving intravenous
penicillin. What does the nurse conclude is the cause of this
reaction?
1
An acquired atopic sensitization occurred.
2
There was passive immunity to the penicillin allergen.
3
Antibodies to penicillin developed after a previous exposure.
4
Potent antibodies were produced when the infusion was
instituted Correct Answers 3
Hypersensitivity results from the production of antibodies in
response to exposure to certain foreign substances (allergens).
Earlier exposure is necessary for the development of these
antibodies. This is not a sensitivity reaction to penicillin; hay
fever and asthma are atopic conditions. It is an active, not
Practice Test, UNIT 1: Foundations of Nursing Practice
Questions With Complete Solutions
"It shows the time needed for the SA node impulse to depolarize
the atria and travel through the AV node."
Explanation:
The PR interval is measured from the beginning of the P wave to
the beginning of the QRS complex and represents the time
needed for sinus node stimulation, atrial depolarization, and
conduction through the AV node before ventricular
depolarization. In a normal heart the impulses do not travel
backward. The PR interval does not include the time it take to
travel through the Purkinje fibers Correct Answers P-R interval
0.24 seconds
Explanation:
In adults, the normal range for the PR is 0.12 to 0.20 seconds. A
PR internal of 0.24 seconds would indicate a first-degree heart
block. Correct Answers Which PR interval presents a first-
degree heart block?
A 73-year-old female client had a hemiarthroplasty of the left
hip yesterday due to a fracture resulting from a fall. In reviewing
hip precautions with the client, which instruction should the
nurse include in this client's teaching plan?
A. In 8 weeks you will be able to bend at the waist to reach
items on the floor.
B. Place a pillow between your knees while lying in bed to
prevent hip dislocation.
,C. It is safe to use a walker to get out of bed, but you need
assistance when walking.
D. Take pain medication 30 minutes after your physical therapy
sessions. Correct Answers The client's affected hip joint
following a hemiarthroplasty (partial hip replacement) is at risk
of dislocation for 6 months to a year following the procedure.
Hip precautions to prevent dislocation include placing a pillow
between the knees to maintain abduction of the hips (B). Clients
should be instructed to avoid bending at the waist (A), to seek
assistance for both standing and walking until they are stable on
a walker or cane (C), and to take pain medication 20 to 30
minutes prior to physical therapy sessions, rather than waiting
until the pain level is high after their therapy.
Correct Answer: B
A client asks about the purpose of a pulse oximeter. The nurse
explains that it is used to measure the:
1
Respiratory rate.
2
Amount of oxygen in the blood.
3
Percentage of hemoglobin-carrying oxygen.
4
Amount of carbon dioxide in the blood Correct Answers 3
The pulse oximeter measures the oxygen saturation of blood by
determining the percentage of hemoglobin-carrying oxygen. A
pulse oximeter does not interpret the amount of oxygen or
carbon dioxide carried in the blood, nor does it measure
respiratory rate.
,A client comes to the clinic complaining of a productive cough
with copious yellow sputum, fever, and chills for the past two
days. The first thing the nurse should do when caring for this
client is to:
1
Encourage fluids.
2
Administer oxygen.
3
Take the temperature.
4
Collect a sputum specimen Correct Answers 3
Baseline vital signs are extremely important; physical
assessment precedes diagnostic measures and intervention. This
is done after the health care provider makes a medical diagnosis;
this is not an independent function of the nurse. Encouraging
fluids might be done after it is determined whether a specimen
for blood gases is needed; this is not usually an independent
function of the nurse. Oxygen is administered independently by
the nurse only in an emergency situation. A sputum specimen
should be obtained after vital signs and before administration of
antibiotics.
A client has a pressure ulcer that is full thickness with necrosis
into the subcutaneous tissue down to the underlying fascia. The
nurse should document the assessment finding as which stage of
pressure ulcer?
1
Stage I
2
Stage II
, 3
Stage III
4
Unstageable Correct Answers 4
A pressure ulcer with necrotic tissue is unstageable. The necrotic
tissue must be removed before the wound can be staged. A stage
I pressure ulcer is defined as an area of persistent redness with
no break in skin integrity. A stage II pressure ulcer is a partial-
thickness wound with skin loss involving the epidermis, dermis,
or both; the ulcer is superficial and may present as an abrasion,
blister, or shallow crater. A stage III pressure ulcer involves full
thickness tissue loss with visible subcutaneous fat. Bone,
tendon, and muscle are not exposed.
A client has an anaphylactic reaction after receiving intravenous
penicillin. What does the nurse conclude is the cause of this
reaction?
1
An acquired atopic sensitization occurred.
2
There was passive immunity to the penicillin allergen.
3
Antibodies to penicillin developed after a previous exposure.
4
Potent antibodies were produced when the infusion was
instituted Correct Answers 3
Hypersensitivity results from the production of antibodies in
response to exposure to certain foreign substances (allergens).
Earlier exposure is necessary for the development of these
antibodies. This is not a sensitivity reaction to penicillin; hay
fever and asthma are atopic conditions. It is an active, not
