Foundations-HESI Exam: Questions
and A+ Answers
Rectal Temp - Insert lubricated thermometer probe(w/cover) into rectum 1-1.5in toward
umbilicus; reading is usually 0.9F greater than oral temp
Axillary Temp - Place thermometer probe in center of axilla; have pt place arm across
chest; reading is usually 0.9F lower than oral temp
Orthostatic BP readings - Orthostatic hypotension aka postural hypotension; obtain
supine, sitting, & standing(1-3 min between each); observe pt for dizziness, fainting,
lightheadedness; record pts position with each reading; DO NOT DELEGATE
Exercise & Sleep - Exercise 2hrs before bedtime; allows cool down period and fatigue
that promotes relaxation
Soaking Feet - Part of routine pt hygiene; DO NOT soak feet of pts with diabetes or
other peripheral vascular disorders. Can delegate to NAP, but NAP CANNOT trim nails;
Soak feet for 10-20 min in warm water, rewarm water after 10min; Nurse can trim nails
using clippers, straight across and even with fingertips; DO NOT trim in pts with
circulatory problems; Dry thoroughly, apply lotion.
Indwelling Catheter - Ambulation; never raise drainage bag above level of bladder; prior
to ambulation, drain all urine from tubing into drainage bag
False-low readings on BP cuff - cuff to wide, arm above heart level
False-high readings on BP cuff - cuff to narrow/short, cuff to loose or uneven, arm not
supported
False-high diastolic readings on BP cuff - deflating cuff to slowly, inflating to slowly
Normal vitals - RR: 12-20
BP:<120/<80
HR: 60-100
Temp: 98.6F or 37C
Pulse Defecit - Assess radial and apical pulses simultaneously. The pulse defecit is the
difference between the two due to an inefficient contraction of the heart that fails to
transmit a pulse wave to peripheral pulse sites
Hygiene-self care defecit - results from side effects of medication, lack of knowledge,
immobilization, an inability to perform hygiene,, or physical condition that potentially
injures the skin, mouth, feet, nails or hair.
, Hygiene Assessment - include patient's muscle strength, flexibility, balance, visual
acuity, and ability to detect thermal and tactile stimuli, metal status, activity
tolerance(RR, skin color, pulse)
Applying TED hose(antiembolitic stockings) - 1. Obtain order from MD
2. Measure leg
3. Explain to patient
4. Hand hygiene
5. Supine position
6.Turn elastic inside out up to heal, pull over feet, pull all the way up calf, making sure
there are no wrinkles.
7. Remove them at least once per shift
8. Observe circulatory status of lower extremities; color temperature, and condition of
skin, palpate pedal pulses.
Ostomy Care Patient Teaching - Provide pt with supplies to last 1-2 weeks, with info on
closet supply company; show them step by step for changing pouch; provide at lease
one chance for pt to change pouch while in hospital; arrange visits from community
stoma care nurse; provide detailed discharge instructions for skin care, clothing, driving,
lifting, resuming exercise, when to contact MD
Bowel Training - Assess normal elimination patter; choose a time in t patients pattern to
initiate defecation control measures; give stool softeners every day at least 30 min prior
to selected time; offer a hot drink( hot tea) or juice (prune juice) or whatever fluid that
stimulates peristalsis for pt; help pt to toilet at time; avoid meds that can constipate;
provide privacy and set time frame for 15-20 mins for defecation; have pt lean forward
at thips while sitting on toilet, apply manual pressure with hands over abdomen, and
bear down but not strain to stimulate emptying; do not criticize or convey frustration if pt
can't defecate; maintain normal exercise within pt ability
Bowel Retraining in Elderly - Coarse bran rather than refined fiber is more effective in
increasing stool weight; a minimum of 1500mL of fluid per day reduces risk of
constipation; if holding a cup is to much, give smaller lighter cup, fill frequently; fruit
juices increase fiber content and fluids; encourage regular exercise; pt needs to feel at
ease during elimination(give privacy); review all meds, look for alternatives to
constipating meds; behavioral interventions such as habit training provide relief of
constipation. Have patient sit on toilet about 30 min after a meal, whether they have to
defecate or not.
Risk for Falls - Assessment should be done during admission, following a change in
patient condition, after a fall, and when transferred; if pt is found to be risk, regular
assessment always continues; Age, fall history, bowel and urine elimination, meds,
patient care equipment(IV's, catheters, chest tubes), mobility, cognition MODERATE
RISK: 6-13 points, HIGH RISK: >13 points
and A+ Answers
Rectal Temp - Insert lubricated thermometer probe(w/cover) into rectum 1-1.5in toward
umbilicus; reading is usually 0.9F greater than oral temp
Axillary Temp - Place thermometer probe in center of axilla; have pt place arm across
chest; reading is usually 0.9F lower than oral temp
Orthostatic BP readings - Orthostatic hypotension aka postural hypotension; obtain
supine, sitting, & standing(1-3 min between each); observe pt for dizziness, fainting,
lightheadedness; record pts position with each reading; DO NOT DELEGATE
Exercise & Sleep - Exercise 2hrs before bedtime; allows cool down period and fatigue
that promotes relaxation
Soaking Feet - Part of routine pt hygiene; DO NOT soak feet of pts with diabetes or
other peripheral vascular disorders. Can delegate to NAP, but NAP CANNOT trim nails;
Soak feet for 10-20 min in warm water, rewarm water after 10min; Nurse can trim nails
using clippers, straight across and even with fingertips; DO NOT trim in pts with
circulatory problems; Dry thoroughly, apply lotion.
Indwelling Catheter - Ambulation; never raise drainage bag above level of bladder; prior
to ambulation, drain all urine from tubing into drainage bag
False-low readings on BP cuff - cuff to wide, arm above heart level
False-high readings on BP cuff - cuff to narrow/short, cuff to loose or uneven, arm not
supported
False-high diastolic readings on BP cuff - deflating cuff to slowly, inflating to slowly
Normal vitals - RR: 12-20
BP:<120/<80
HR: 60-100
Temp: 98.6F or 37C
Pulse Defecit - Assess radial and apical pulses simultaneously. The pulse defecit is the
difference between the two due to an inefficient contraction of the heart that fails to
transmit a pulse wave to peripheral pulse sites
Hygiene-self care defecit - results from side effects of medication, lack of knowledge,
immobilization, an inability to perform hygiene,, or physical condition that potentially
injures the skin, mouth, feet, nails or hair.
, Hygiene Assessment - include patient's muscle strength, flexibility, balance, visual
acuity, and ability to detect thermal and tactile stimuli, metal status, activity
tolerance(RR, skin color, pulse)
Applying TED hose(antiembolitic stockings) - 1. Obtain order from MD
2. Measure leg
3. Explain to patient
4. Hand hygiene
5. Supine position
6.Turn elastic inside out up to heal, pull over feet, pull all the way up calf, making sure
there are no wrinkles.
7. Remove them at least once per shift
8. Observe circulatory status of lower extremities; color temperature, and condition of
skin, palpate pedal pulses.
Ostomy Care Patient Teaching - Provide pt with supplies to last 1-2 weeks, with info on
closet supply company; show them step by step for changing pouch; provide at lease
one chance for pt to change pouch while in hospital; arrange visits from community
stoma care nurse; provide detailed discharge instructions for skin care, clothing, driving,
lifting, resuming exercise, when to contact MD
Bowel Training - Assess normal elimination patter; choose a time in t patients pattern to
initiate defecation control measures; give stool softeners every day at least 30 min prior
to selected time; offer a hot drink( hot tea) or juice (prune juice) or whatever fluid that
stimulates peristalsis for pt; help pt to toilet at time; avoid meds that can constipate;
provide privacy and set time frame for 15-20 mins for defecation; have pt lean forward
at thips while sitting on toilet, apply manual pressure with hands over abdomen, and
bear down but not strain to stimulate emptying; do not criticize or convey frustration if pt
can't defecate; maintain normal exercise within pt ability
Bowel Retraining in Elderly - Coarse bran rather than refined fiber is more effective in
increasing stool weight; a minimum of 1500mL of fluid per day reduces risk of
constipation; if holding a cup is to much, give smaller lighter cup, fill frequently; fruit
juices increase fiber content and fluids; encourage regular exercise; pt needs to feel at
ease during elimination(give privacy); review all meds, look for alternatives to
constipating meds; behavioral interventions such as habit training provide relief of
constipation. Have patient sit on toilet about 30 min after a meal, whether they have to
defecate or not.
Risk for Falls - Assessment should be done during admission, following a change in
patient condition, after a fall, and when transferred; if pt is found to be risk, regular
assessment always continues; Age, fall history, bowel and urine elimination, meds,
patient care equipment(IV's, catheters, chest tubes), mobility, cognition MODERATE
RISK: 6-13 points, HIGH RISK: >13 points
