Hesi critical thinking Questions and
Answers 100% Pass
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
...
Hesi critical thinking Questions and
Answers 100% Pass
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
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 medications 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
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
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 circulation 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
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.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
D. An elderly man being treated for a peptic ulcer. ✔✔A lactating woman (B) has the greatest
need for additional protein intake. (A, C, and D) are all conditions that require protein, but do not
have the increased metabolic protein demands of lactation.
Correct Answer: B
A client is in the radiology department at 0900 when the prescription levofloxacin (Levaquin)
500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is
the best intervention for the nurse to implement?
A. Contact the healthcare provider and complete a medication variance form.
B. Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.
C. Notify the charge nurse and complete an incident report to explain the missed dose.
D. Give the missed dose at 1300 and change the schedule to administer daily at 1300. ✔✔To
ensure that a therapeutic level of medication is maintained, the nurse should administer the
missed dose as soon as possible, and revise the administration schedule accordingly to prevent
dangerously increasing the level of the medication in the bloodstream (D). The nurse should
document the reason for the late dose, but (A and C) are not
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