Hesi Fundamentals Practice Test
1. An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.: To avoid shearing
forces when repositioning, the client should be lifted gently across a surface (D).
Reddened areas should not be massaged (A) since this may increase the damage
to already traumatized skin. To control pain and muscle spasms, active range of
motion (B) may be limited on the affected leg. The position described in (C) is
contraindicated for a client with a fractured left hip.
Correct Answer: D
2. The nurse is administering medications through a nasogastric tube (NGT)
which is connected to suction. After ensuring correct tube placement, what
action should the nurse take next?
,A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.: The NGT should be flushed
before, after and in between each medication administered (B). Once all medica-
tions are administered, the NGT should be clamped for 20 minutes (A). (C and D)
may be implemented only after the tubing has been flushed.
Correct Answer: B
3. A client who is in hospice care complains of increasing amounts of pain.
The healthcare provider prescribes an analgesic every four hours as needed.
Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.-
: The most effective management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis (A) and in a
,timely manner. Analgesics are less effective if pain persists until it is severe, so an
analgesic medication should be administered before the client's pain peaks (B).
Providing comfort is a priority for the client who is dying, but sedation that impairs
the client's ability to interact and experience the time before life ends should be
minimized (C). Offering a medication-free period allows the serum drug level to
, fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
4. When assessing a client with wrist restraints, the nurse observes that the
fingers on the right hand are blue. What action should the nurse implement
first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.: The priority nursing action is to restore cir-
culation by loosening the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing interventions, but
do not have the priority of (A). Pulse oximetry (B) measures the saturation of
hemoglobin with oxygen and is not indicated in situations where the cyanosis is
related to mechanical compression (the restraints).
Correct Answer: A
5. The nurse is assessing the nutritional status of several clients. Which
client has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
1. An elderly client with a fractured left hip is on strict bedrest. Which nursing
measure is essential to the client's nursing care?
A. Massage any reddened areas for at least five minutes.
B. Encourage active range of motion exercises on extremities.
C. Position the client laterally, prone, and dorsally in sequence.
D. Gently lift the client when moving into a desired position.: To avoid shearing
forces when repositioning, the client should be lifted gently across a surface (D).
Reddened areas should not be massaged (A) since this may increase the damage
to already traumatized skin. To control pain and muscle spasms, active range of
motion (B) may be limited on the affected leg. The position described in (C) is
contraindicated for a client with a fractured left hip.
Correct Answer: D
2. The nurse is administering medications through a nasogastric tube (NGT)
which is connected to suction. After ensuring correct tube placement, what
action should the nurse take next?
,A. Clamp the tube for 20 minutes.
B. Flush the tube with water.
C. Administer the medications as prescribed.
D. Crush the tablets and dissolve in sterile water.: The NGT should be flushed
before, after and in between each medication administered (B). Once all medica-
tions are administered, the NGT should be clamped for 20 minutes (A). (C and D)
may be implemented only after the tubing has been flushed.
Correct Answer: B
3. A client who is in hospice care complains of increasing amounts of pain.
The healthcare provider prescribes an analgesic every four hours as needed.
Which action should the nurse implement?
A. Give an around-the-clock schedule for administration of analgesics.
B. Administer analgesic medication as needed when the pain is severe.
C. Provide medication to keep the client sedated and unaware of stimuli.
D. Offer a medication-free period so that the client can do daily activities.-
: The most effective management of pain is achieved using an around-the-clock
schedule that provides analgesic medications on a regular basis (A) and in a
,timely manner. Analgesics are less effective if pain persists until it is severe, so an
analgesic medication should be administered before the client's pain peaks (B).
Providing comfort is a priority for the client who is dying, but sedation that impairs
the client's ability to interact and experience the time before life ends should be
minimized (C). Offering a medication-free period allows the serum drug level to
, fall, which is not an effective method to manage chronic pain (D).
Correct Answer: A
4. When assessing a client with wrist restraints, the nurse observes that the
fingers on the right hand are blue. What action should the nurse implement
first?
A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.: The priority nursing action is to restore cir-
culation by loosening the restraint (A), because blue fingers (cyanosis) indicates
decreased circulation. (C and D) are also important nursing interventions, but
do not have the priority of (A). Pulse oximetry (B) measures the saturation of
hemoglobin with oxygen and is not indicated in situations where the cyanosis is
related to mechanical compression (the restraints).
Correct Answer: A
5. The nurse is assessing the nutritional status of several clients. Which
client has the greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
