HESI PN Fundamentals
D. Gently lift the client when moving into
An elderly client with a fractured left hip is a desired position.
on strict bedrest. Which nursing measure
is essential to the client's nursing care? To avoid shearing forces when reposi-
tioning, the client should be lifted gen-
A. Massage any reddened areas for at tly across a surface (D). Reddened ar-
least five minutes. eas should not be massaged (A) since
B. Encourage active range of motion ex- this may increase the damage to al-
ercises on extremities. ready traumatized skin. To control pain
C. Position the client laterally, prone, and and muscle spasms, active range of mo-
dorsally in sequence. tion (B) may be limited on the affected
D. Gently lift the client when moving into leg. The position described in (C) is con-
a desired position. traindicated for a client with a fractured
left hip.
The nurse is administering medications
through a nasogastric tube (NGT) which
B. Flush the tube with water.
is connected to suction. After ensur-
ing correct tube placement, what action
The NGT should be flushed before, after
should the nurse take next?
and in between each medication admin-
istered (B). Once all medications are ad-
A. Clamp the tube for 20 minutes.
ministered, the NGT should be clamped
B. Flush the tube with water.
for 20 minutes (A). (C and D) may be
C. Administer the medications as pre-
implemented only after the tubing has
scribed.
been flushed.
D. Crush the tablets and dissolve in ster-
ile water.
A. Give an around-the-clock schedule for
A client who is in hospice care com- administration of analgesics.
plains of increasing amounts of pain. The
healthcare provider prescribes an anal- The most effective management of pain
gesic every four hours as needed. Which is achieved using an around-the-clock
action should the nurse implement? schedule that provides analgesic med-
ications on a regular basis (A) and in
A. Give an around-the-clock schedule for a timely manner. Analgesics are less
administration of analgesics. effective if pain persists until it is se-
B. Administer analgesic medication as vere, so an analgesic medication should
needed when the pain is severe. be administered before the client's pain
peaks (B). Providing comfort is a priority
, HESI PN Fundamentals
for the client who is dying, but sedation
that impairs the client's ability to inter-
C. Provide medication to keep the client
act and experience the time before life
sedated and unaware of stimuli.
ends should be minimized (C). Offering a
D. Offer a medication-free period so that
medication-free period allows the serum
the client can do daily activities.
drug level to fall, which is not an effective
method to manage chronic pain (D).
A. Loosen the right wrist restraint.
When assessing a client with wrist re-
The priority nursing action is to restore
straints, the nurse observes that the fin-
circulation by loosening the restraint (A),
gers on the right hand are blue. What
because blue fingers (cyanosis) indi-
action should the nurse implement first?
cates decreased circulation. (C and D)
are also important nursing interventions,
A. Loosen the right wrist restraint.
but do not have the priority of (A). Pulse
B. Apply a pulse oximeter to the right
oximetry (B) measures the saturation of
hand.
hemoglobin with oxygen and is not indi-
C. Compare hand color bilaterally.
cated in situations where the cyanosis is
D. Palpate the right radial pulse.
related to mechanical compression (the
restraints).
The nurse is assessing the nutritional
status of several clients. Which client has
the greatest nutritional need for addition-
B. A lactating woman nursing her
al intake of protein?
3-day-old infant.
A. A college-age track runner with a
A lactating woman (B) has the greatest
sprained ankle.
need for additional protein intake. (A, C,
B. A lactating woman nursing her
and D) are all conditions that require
3-day-old infant.
protein, but do not have the increased
C. A school-aged child with Type 2 dia-
metabolic protein demands of lactation.
betes.
D. An elderly man being treated for a
peptic ulcer.
A client is in the radiology department at
D. Give the missed dose at 1300 and
0900 when the prescription levofloxacin
change the schedule to administer daily
(Levaquin) 500 mg IV q24h is scheduled
at 1300.
to be administered. The client returns to
the unit at 1300. What is the best inter-
, HESI PN Fundamentals
vention for the nurse to implement?
To ensure that a therapeutic level of med-
A. Contact the healthcare provider and ication is maintained, the nurse should
complete a medication variance form. administer the missed dose as soon as
B. Administer the Levaquin at 1300 and possible, and revise the administration
resume the 0900 schedule in the morn- schedule accordingly to prevent danger-
ing. ously increasing the level of the medica-
C. Notify the charge nurse and complete tion in the bloodstream (D). The nurse
an incident report to explain the missed should document the reason for the late
dose. dose, but (A and C) are not warranted.
D. Give the missed dose at 1300 and (B) could result in increased blood levels
change the schedule to administer daily of the drug.
at 1300.
While instructing a male client's wife in
the performance of passive range-of-mo-
tion exercises to his contracted shoul- A. Acknowledge that she is supporting
der, the nurse observes that she is hold- the arm correctly.
ing his arm above and below the elbow.
What nursing action should the nurse The wife is performing the passive ROM
implement? correctly, therefore the nurse should ac-
knowledge this fact (A). The joint that is
A. Acknowledge that she is supporting being exercised should be uncovered (B)
the arm correctly. while the rest of the body should remain
B. Encourage her to keep the joint cov- covered for warmth and privacy. (C and
ered to maintain warmth. D) do not provide adequate support to
C. Reinforce the need to grip directly un- the joint while still allowing for joint move-
der the joint for better support. ment.
D. Instruct her to grip directly over the
joint for better motion.
B. A decreased flow rate could result in
What is the most important reason for
the formation of a thrombosis.
starting intravenous infusions in the up-
per extremities rather than the lower ex-
Venous return is usually better in the up-
tremities of adults?
per extremities. Cannulation of the veins
in the lower extremities increases the risk
A. It is more difficult to find a superficial
of thrombus formation (B) which, if dis-
vein in the feet and ankles.
lodged, could be life-threatening. Super-
B. A decreased flow rate could result in
ficial veins are often very easy (A) to find
, HESI PN Fundamentals
in the feet and legs. Handling a leg or foot
the formation of a thrombosis. with an IV (C) is probably not any more
C. A cannulated extremity is more diffi- difficult than handling an arm or hand.
cult to move when the leg or foot is used. Even if the nurse did believe moving a
D. Veins are located deep in the feet and cannulated leg was more difficult, this is
ankles, resulting in a more painful proce- not the most important reason for using
dure. the upper extremities. Pain (D) is not a
consideration.
The nurse observes an unlicensed as-
sistive personnel (UAP) taking a client's
blood pressure with a cuff that is too
small, but the blood pressure reading ob- B. Reassess the client's blood pressure
tained is within the client's usual range. using a larger cuff.
What action is most important for the
nurse to implement? The most important action is to ensure
that an accurate BP reading is obtained.
A. Tell the UAP to use a larger cuff at the The nurse should reassess the BP with
next scheduled assessment. the correct size cuff (B). Reassessment
B. Reassess the client's blood pressure should not be postponed (A). Though (C
using a larger cuff. and D) are likely indicated, these actions
C. Have the unit educator review this pro- do not have the priority of (B).
cedure with the UAPs.
D. Teach the UAP the correct technique
for assessing blood pressure.
Twenty minutes after beginning a heat
application, the client states that the
heating pad no longer feels warm
D. The body's receptors adapt over time
enough. What is the best response by
as they are exposed to heat.
the nurse?
(D) describes thermal adaptation, which
A. That means you have derived the
occurs 20 to 30 minutes after heat appli-
maximum benefit, and the heat can be
cation. (A and B) provide false informa-
removed.
tion. (C) is not based on a knowledge of
B. Your blood vessels are becoming dilat-
physiology and is an unsafe action that
ed and removing the heat from the site.
may harm the client.
C. We will increase the temperature 5
degrees when the pad no longer feels
warm.
D. Gently lift the client when moving into
An elderly client with a fractured left hip is a desired position.
on strict bedrest. Which nursing measure
is essential to the client's nursing care? To avoid shearing forces when reposi-
tioning, the client should be lifted gen-
A. Massage any reddened areas for at tly across a surface (D). Reddened ar-
least five minutes. eas should not be massaged (A) since
B. Encourage active range of motion ex- this may increase the damage to al-
ercises on extremities. ready traumatized skin. To control pain
C. Position the client laterally, prone, and and muscle spasms, active range of mo-
dorsally in sequence. tion (B) may be limited on the affected
D. Gently lift the client when moving into leg. The position described in (C) is con-
a desired position. traindicated for a client with a fractured
left hip.
The nurse is administering medications
through a nasogastric tube (NGT) which
B. Flush the tube with water.
is connected to suction. After ensur-
ing correct tube placement, what action
The NGT should be flushed before, after
should the nurse take next?
and in between each medication admin-
istered (B). Once all medications are ad-
A. Clamp the tube for 20 minutes.
ministered, the NGT should be clamped
B. Flush the tube with water.
for 20 minutes (A). (C and D) may be
C. Administer the medications as pre-
implemented only after the tubing has
scribed.
been flushed.
D. Crush the tablets and dissolve in ster-
ile water.
A. Give an around-the-clock schedule for
A client who is in hospice care com- administration of analgesics.
plains of increasing amounts of pain. The
healthcare provider prescribes an anal- The most effective management of pain
gesic every four hours as needed. Which is achieved using an around-the-clock
action should the nurse implement? schedule that provides analgesic med-
ications on a regular basis (A) and in
A. Give an around-the-clock schedule for a timely manner. Analgesics are less
administration of analgesics. effective if pain persists until it is se-
B. Administer analgesic medication as vere, so an analgesic medication should
needed when the pain is severe. be administered before the client's pain
peaks (B). Providing comfort is a priority
, HESI PN Fundamentals
for the client who is dying, but sedation
that impairs the client's ability to inter-
C. Provide medication to keep the client
act and experience the time before life
sedated and unaware of stimuli.
ends should be minimized (C). Offering a
D. Offer a medication-free period so that
medication-free period allows the serum
the client can do daily activities.
drug level to fall, which is not an effective
method to manage chronic pain (D).
A. Loosen the right wrist restraint.
When assessing a client with wrist re-
The priority nursing action is to restore
straints, the nurse observes that the fin-
circulation by loosening the restraint (A),
gers on the right hand are blue. What
because blue fingers (cyanosis) indi-
action should the nurse implement first?
cates decreased circulation. (C and D)
are also important nursing interventions,
A. Loosen the right wrist restraint.
but do not have the priority of (A). Pulse
B. Apply a pulse oximeter to the right
oximetry (B) measures the saturation of
hand.
hemoglobin with oxygen and is not indi-
C. Compare hand color bilaterally.
cated in situations where the cyanosis is
D. Palpate the right radial pulse.
related to mechanical compression (the
restraints).
The nurse is assessing the nutritional
status of several clients. Which client has
the greatest nutritional need for addition-
B. A lactating woman nursing her
al intake of protein?
3-day-old infant.
A. A college-age track runner with a
A lactating woman (B) has the greatest
sprained ankle.
need for additional protein intake. (A, C,
B. A lactating woman nursing her
and D) are all conditions that require
3-day-old infant.
protein, but do not have the increased
C. A school-aged child with Type 2 dia-
metabolic protein demands of lactation.
betes.
D. An elderly man being treated for a
peptic ulcer.
A client is in the radiology department at
D. Give the missed dose at 1300 and
0900 when the prescription levofloxacin
change the schedule to administer daily
(Levaquin) 500 mg IV q24h is scheduled
at 1300.
to be administered. The client returns to
the unit at 1300. What is the best inter-
, HESI PN Fundamentals
vention for the nurse to implement?
To ensure that a therapeutic level of med-
A. Contact the healthcare provider and ication is maintained, the nurse should
complete a medication variance form. administer the missed dose as soon as
B. Administer the Levaquin at 1300 and possible, and revise the administration
resume the 0900 schedule in the morn- schedule accordingly to prevent danger-
ing. ously increasing the level of the medica-
C. Notify the charge nurse and complete tion in the bloodstream (D). The nurse
an incident report to explain the missed should document the reason for the late
dose. dose, but (A and C) are not warranted.
D. Give the missed dose at 1300 and (B) could result in increased blood levels
change the schedule to administer daily of the drug.
at 1300.
While instructing a male client's wife in
the performance of passive range-of-mo-
tion exercises to his contracted shoul- A. Acknowledge that she is supporting
der, the nurse observes that she is hold- the arm correctly.
ing his arm above and below the elbow.
What nursing action should the nurse The wife is performing the passive ROM
implement? correctly, therefore the nurse should ac-
knowledge this fact (A). The joint that is
A. Acknowledge that she is supporting being exercised should be uncovered (B)
the arm correctly. while the rest of the body should remain
B. Encourage her to keep the joint cov- covered for warmth and privacy. (C and
ered to maintain warmth. D) do not provide adequate support to
C. Reinforce the need to grip directly un- the joint while still allowing for joint move-
der the joint for better support. ment.
D. Instruct her to grip directly over the
joint for better motion.
B. A decreased flow rate could result in
What is the most important reason for
the formation of a thrombosis.
starting intravenous infusions in the up-
per extremities rather than the lower ex-
Venous return is usually better in the up-
tremities of adults?
per extremities. Cannulation of the veins
in the lower extremities increases the risk
A. It is more difficult to find a superficial
of thrombus formation (B) which, if dis-
vein in the feet and ankles.
lodged, could be life-threatening. Super-
B. A decreased flow rate could result in
ficial veins are often very easy (A) to find
, HESI PN Fundamentals
in the feet and legs. Handling a leg or foot
the formation of a thrombosis. with an IV (C) is probably not any more
C. A cannulated extremity is more diffi- difficult than handling an arm or hand.
cult to move when the leg or foot is used. Even if the nurse did believe moving a
D. Veins are located deep in the feet and cannulated leg was more difficult, this is
ankles, resulting in a more painful proce- not the most important reason for using
dure. the upper extremities. Pain (D) is not a
consideration.
The nurse observes an unlicensed as-
sistive personnel (UAP) taking a client's
blood pressure with a cuff that is too
small, but the blood pressure reading ob- B. Reassess the client's blood pressure
tained is within the client's usual range. using a larger cuff.
What action is most important for the
nurse to implement? The most important action is to ensure
that an accurate BP reading is obtained.
A. Tell the UAP to use a larger cuff at the The nurse should reassess the BP with
next scheduled assessment. the correct size cuff (B). Reassessment
B. Reassess the client's blood pressure should not be postponed (A). Though (C
using a larger cuff. and D) are likely indicated, these actions
C. Have the unit educator review this pro- do not have the priority of (B).
cedure with the UAPs.
D. Teach the UAP the correct technique
for assessing blood pressure.
Twenty minutes after beginning a heat
application, the client states that the
heating pad no longer feels warm
D. The body's receptors adapt over time
enough. What is the best response by
as they are exposed to heat.
the nurse?
(D) describes thermal adaptation, which
A. That means you have derived the
occurs 20 to 30 minutes after heat appli-
maximum benefit, and the heat can be
cation. (A and B) provide false informa-
removed.
tion. (C) is not based on a knowledge of
B. Your blood vessels are becoming dilat-
physiology and is an unsafe action that
ed and removing the heat from the site.
may harm the client.
C. We will increase the temperature 5
degrees when the pad no longer feels
warm.
