HESI FUNDAMENTALS PRACTICE EXAM Correct and Verified Answers Graded A

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HESI FUNDAMENTALS PRACTICE EXAM

Correct and Verified Answers Graded A

• Three days following a surgery, a male client observes his colostomy for the first

time. He becomes quite upset and tells the nurse that it is much bigger than he expected. What is the best response by the nurse?

• Reassure the client that he will become accustomed to the stoma appearance in time.
• Instruct the client that the stoma will become much smaller when the initial swelling

diminishes.

• Offer to contact a member of the local ostomy support group to help him with his

concerns.

• Encourage the client to handle the stoma equipment to gain confidence with the

procedure.Correct Answer: B. Instruct the client that the stoma will become smaller when the initial swelling diminishes (Postoperative swelling causes enlargement of the stoma. The nurse can teach the client that the stoma will become smaller when swelling is diminished. This will help reduce the client's anxiety and promote acceptance of the colostomy.)

• The nurse mixes 50 mg of Nipride in 250 mL of D5W and plans to administer the

solution at a rate of 5 mcg/kg/min to a client weighing 182 lbs. Using a drip factor of 60 gtt/mL, how many drops per minute should the client receive?

Correct Answer: 124 gtt/min

• A client with chronic kidney disease (CKD) selects a scrambled egg for his

breakfast. What action should the nurse take?

• Commend the client for selecting a high biologic value protein.
• Remind the client that protein in the diet should be avoided.
• Suggest that the client also select orange juice, to promote absorption.
• Encourage the client to attend classes on dietary management of CKD.

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Correct Answer: A. Commend the client for selecting a high biologic value protein. (Foods such as eggs and milk are high biologic proteins which are allowed because they are complete proteins and supply the essential amino acids.)

• The nurse observes that a male client has removed the covering from an ice pack

applied to his knee. What action should the nurse take first?

• Observe the appearance of the skin under the ice pack.
• Instruct the client regarding the need for the covering.
• Reapply the covering after filling with fresh ice.
• Ask the client how long the ice was applied to the skin.

Correct Answer: A. Observe the appearance of the skin under the ice pack (The first action taken by the nurse should be to assess the skin for any possible thermal injury.)

• A hospitalized male client is receiving nasogastric tube feedings via a small-bore

tube and a continuous pump infusion. He reports that he had a bad bout of severe coughing a few minutes ago, but feels fine now. What action is best for the nurse to take?

• Record the coughing incident. No further action is required at this time.
• Stop the feeding, explain to the family why it is being stopped, and notify the HCP.
• After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.
• Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling.

Correct Answer: C. After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube.

• The healthcare provider prescribes an IV infusion of 1000 ml of Ringer's Lactate w/

30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by cesarean section. The tubing has been changed to a 20 gtt/ml administration set. The nurse plans to set the flow rate at how many gtt/min?

Correct Answer: 83 gtt/min

• A male client tells the nurse that he does not know where he is or what year it is.

What data should the nurse document that is most accurate?

• demonstrates loss of remote memory
• exhibits expressive dysphasia

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• has a diminished attention span
• is disoriented to place and time

Correct Answer: D. is disoriented to place and time

• Which assessment data provides the most accurate determination of proper

placement of a nasogastric tube?

Correct Answer: Examining a chest x-ray obtained after the tubing was inserted

• 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:

Correct Answer: Upper torso (The center of gravity for adults is the hips. However, as the person grows older, a stooped posture results in the upper torso becoming the center of gravity.)

• A female client with a nasogastric tube attached to low suction states that she is

nauseated. The nurse assesses that there has been no drainage through the nasogastric tube in the last two hours. What action should the nurse take first?

• Irrigate the nasogastric tube with sterile normal saline.
• Reposition the client on her side.
• Advance the nasogastric tube an additional five centimeters.
• Administer an intravenous antiemetic prescribed for PRN use.

Correct Answer: B. Reposition the client on her side. (The immediate priority is to determine if the tube is functioning correctly, which would then relieve the client's nausea.The least invasive intervention should be attempted first.)

• In developing a plan of care for a client with dementia, the nurse should remember

that confusion in the elderly:

• is to be expected, and progresses with age
• often follows relocation to new surroundings
• is a result of irreversible brain pathology
• can be prevented with adequate sleep

Correct Answer: B. often follows relocation to new surroundings

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• A postoperative client will need to perform daily dressing changes after discharge.

Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?

• The client asks relevant questions regarding the dressing change
• The client states he will be able to complete the wound care regimen
• The client demonstrates the wound care procedure correctly
• The client has all the necessary supplies for wound care

Correct Answer: C. demonstrates the wound care procedure correctly

• 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?

• What is your daily calorie consumption?
• What vitamin and mineral supplements do you take?"
• "Do you feel that you are overweight?"
• "Will a clear liquid diet be okay after surgery?"

Correct Answer: B. "What vitamin and mineral supplements do you take?"

• During the initial morning assessment, a male client denies dysuria but reports

that his urine appears dark amber. Which intervention should the nurse implement?

• Provide additional coffee on the client's breakfast tray.
• Exchange the client's grape juice for cranberry juice.
• Bring the client additional fruit at mid-morning.
• Encourage additional oral intake of juices and water.

Correct Answer: D. Encourage additional oral intake of juices and water.

• Which intervention is most important for the nurse to implement for a male client

who is experiencing urinary retention?

• Apply a condom catheter
• Apply a skin protectant
• Encourage increased fluid intake