of Nursing Practice | Verified Questions &
Correct Answers | Comprehensive Review for
HESI Exam Success.
Which assessment data would provide the most accurate determination of proper placement of
a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length was inserted.
C) Examining a chest x-ray obtained after the tubing was inserted
Both (A and B) are methods used to determine proper placement of the NG tubing. However,
the best indicator that the tubing is properly placed is (C). (D) is not an indicator of proper
placement
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize that the
center of gravity for an elderly person is the
A) Arms.
B) Upper torso.
C) Head.
D) Feet
B) Upper torso
The center of gravity for adults is the hips. However, as the person grows older, a stooped
posture is common because of the changes from osteoporosis and normal bone degeneration,
and the knees, hips, and elbows flex. This stooped posture results in the upper torso (B)
becoming the center of gravity for older persons. Although (A) is a part, or an extension of the
upper torso, this is not the best and most complete answer.
Which action is most important for the nurse to implement when donning sterile gloves?
,A) Maintain thumb at a ninety degree angle.
B) Hold hands with fingers down while gloving.
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first.
C) Keep gloved hands above the elbows
Gloved hands held below waist level are considered unsterile (C). (A and B) are not essential to
maintaining asepsis. While it may be helpful to put the glove on the dominant hand first, it is
not necessary to ensure asepsis (D).
An adult male client with a history of hypertension tells the nurse that he is tired of taking
antihypertensive medications and is going to try spiritual meditation instead. What should be
the nurse's first response?
A) It is important that you continue your medication while learning to meditate.
B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C) Obtain your healthcare provider's permission before starting meditation.
D) Complementary therapy and western medicine can be effective for you.
A) It is important that you continue your medication while learning to meditate
The prolonged practice of meditation may lead to a reduced need for antihypertensive
medications. However, the medications must be continued (A) while the physiologic response to
meditation is monitored. (B) is not as important as continuing the medication. The healthcare
provider should be informed, but permission is not required to meditate (C). Although it is true
that this complimentary therapy might be effective (D), it is essential that the client continue
with antihypertensive medications until the effect of meditation can be measured
The nurse plans to obtain health assessment information from a primary source. Which option
is a primary source for the completion of the health assessment?
A) Client.
B) Healthcare provider.
C) A family member.
D) Previous medical records
A) Client
A primary source of information for a health assessment is the client (A). (B, C, and D) are
, considered secondary sources about the client's health history, but other details, such as
subjective data, can only be provided directly from the client.
The nurse is instructing a client with high cholesterol about diet and life style modification.
What comment from the client indicates that the teaching has been effective?
A) If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B) I need to avoid eating proteins, including red meat.
C) I will limit my intake of beef to 4 ounces per week.
D) My blood level of low density lipoproteins needs to increase.
C) I will limit my intake of beef to 4 ounces per week
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C) is an
important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the
client should exercise 30 minutes per day, or at least 4 to 6 times per week (A). Red meat and all
proteins do not need to be eliminated (B) to lower cholesterol, but should be restricted to lean
cuts of red meat and smaller portions (2-ounce servings). The low density lipoproteins (D) need
to decrease rather than increase
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 to 0.5 cm in diameter. How should the
nurse record this finding?
A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter
Macules are localized flat skin discolorations less than 1 cm in diameter. However, when
recording such a finding the nurse should describe the appearance (B) rather than simply
naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect description given
the symptoms listed. (C) identifies papules -- solid elevated lesions, again not correctly
identifying the symptoms. (D) identifies petechiae -- pinpoint red to purple skin discolorations
that do not itch, again an incorrect identification
A client who is 5' 5" tall and weighs 200 pounds is scheduled for surgery the next day. What
question is most important for the nurse to include during the preoperative assessment?