HESI FUNDAMENTALS QUESTIONS WITH
DETAILED VERIFIED CORRECT ANSWERS
The nurse is caring for a client who is receiving 24-hr TPN via central line at 54 ml/hr.
When initially assessing the client, the nurse notes that the TPN solution has run out and
the next TPN solution is not avail. What immediate action should the nurse take?
1-discontinue the IV and flush the port w/ heparin
2-infuse 10% dextrose and water at 54 ml/hr ****
3- infuse normal saline at a keep vein open rate
4- obtain a stat blood glucose level and notify the healthcare provider
(TPN is discontinued gradually to allow the client to adj to decreased levels of glucose. Admin
10% dextrose in water at the Rx rate will keep the client from exp hypoglycemia until the next
TPN solution is avail. The client could exp a hypoglycemic reaction if the current level of
glucose is not maintained or if the TPN is discont abruply).
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint of 0.5 cm in diameter. How should the
nurse record this finding?
1-several areas of red, papular lesions from pinpoint to 0.5 cm in size
2-localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter ***
3-localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter
4- multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm
(macules are localized flat skin discolorations less than 1 cm in diameter. When recording such
a finding the nurse should describe the appearance rather than simply naming the condition)
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
15 seconds, large amounts of thick yellow secretions return. What action should the nurse
implement next?
, 1-advise the client to increase the intake of fluids
2-re-oxygenate the client before attempting to suction again ***
3- encourage the client to cough to help loosen secretions
4-rotate the suction cath to obtain any renaming secretions.
(suctioning should not be continued for longer than 10-15 sec)
4 elements of malpractice:
breach of duty owed, failure to adhere to the recognized standard of care, direct causation
of injury, evidence of actual injury.
An elderly client w/ a fractured left hip is on strict bedrest. Ch nursing measure is essential
to the client's nursing care?
1-gently lift the client when moving into a desired position ****
2- position the client laterally, prone, dorsally in sequence
3- encourage active ROM exercises on extremities
4-massage any reddened areas for at least 5 min
(to avoid shearing forces when re positioning,t eh client should be lifted gently across a
surface. To control pain and muscle spasms, active ROM may be limited on the affected leg.)
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next?
1-prioritize nursing care interventions
2-det the etiology of the problem ****
3-collaborate w/ the client to set goals
4-plan appropriate interventions
(before planning care, the nurse should det the etiology/cause of the problem)
What is the most impt reason for starting IV infusions in the upper extremities rather
than the lower extremities of adults?
DETAILED VERIFIED CORRECT ANSWERS
The nurse is caring for a client who is receiving 24-hr TPN via central line at 54 ml/hr.
When initially assessing the client, the nurse notes that the TPN solution has run out and
the next TPN solution is not avail. What immediate action should the nurse take?
1-discontinue the IV and flush the port w/ heparin
2-infuse 10% dextrose and water at 54 ml/hr ****
3- infuse normal saline at a keep vein open rate
4- obtain a stat blood glucose level and notify the healthcare provider
(TPN is discontinued gradually to allow the client to adj to decreased levels of glucose. Admin
10% dextrose in water at the Rx rate will keep the client from exp hypoglycemia until the next
TPN solution is avail. The client could exp a hypoglycemic reaction if the current level of
glucose is not maintained or if the TPN is discont abruply).
Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint of 0.5 cm in diameter. How should the
nurse record this finding?
1-several areas of red, papular lesions from pinpoint to 0.5 cm in size
2-localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter ***
3-localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter
4- multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm
(macules are localized flat skin discolorations less than 1 cm in diameter. When recording such
a finding the nurse should describe the appearance rather than simply naming the condition)
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
15 seconds, large amounts of thick yellow secretions return. What action should the nurse
implement next?
, 1-advise the client to increase the intake of fluids
2-re-oxygenate the client before attempting to suction again ***
3- encourage the client to cough to help loosen secretions
4-rotate the suction cath to obtain any renaming secretions.
(suctioning should not be continued for longer than 10-15 sec)
4 elements of malpractice:
breach of duty owed, failure to adhere to the recognized standard of care, direct causation
of injury, evidence of actual injury.
An elderly client w/ a fractured left hip is on strict bedrest. Ch nursing measure is essential
to the client's nursing care?
1-gently lift the client when moving into a desired position ****
2- position the client laterally, prone, dorsally in sequence
3- encourage active ROM exercises on extremities
4-massage any reddened areas for at least 5 min
(to avoid shearing forces when re positioning,t eh client should be lifted gently across a
surface. To control pain and muscle spasms, active ROM may be limited on the affected leg.)
After completing an assessment and determining that a client has a problem, which action
should the nurse perform next?
1-prioritize nursing care interventions
2-det the etiology of the problem ****
3-collaborate w/ the client to set goals
4-plan appropriate interventions
(before planning care, the nurse should det the etiology/cause of the problem)
What is the most impt reason for starting IV infusions in the upper extremities rather
than the lower extremities of adults?
