Key Fundamentals Skills HESI Practice Exam

1.ID: 310989309 An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?  Massage any reddened areas for at least five minutes.  Encourage acti ...

1.ID: 310989309 An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?  Massage any reddened areas for at least five minutes.  Encourage active range of motion exercises on extremities.  Position the client laterally, prone, and dorsally in sequence.  Gently lift the client when moving into a desired position. Correct 2.ID: 311018751 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?  Clamp the tube for 20 minutes.  Flush the tube with water. Correct  Administer the medications as prescribed.  Crush the tablets and dissolve in sterile water. 3.ID: 310953495 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?  Give an around-the-clock schedule for administration of analgesics. Correct  Administer analgesic medication as needed when the pain is severe.  Provide medication to keep the client sedated and unaware of stimuli.  Offer a medication-free period so that the client can do daily activities. 4.ID: 310965989 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?  Loosen the right wrist restraint. Correct  Apply a pulse oximeter to the right hand.  Compare hand color bilaterally.  Palpate the right radial pulse. 5.ID: 310959857 The nurse is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?  A college-age track runner with a sprained ankle.  A lactating woman nursing her 3-day-old infant. Correct  A school-aged child with Type 2 diabetes.  An elderly man being treated for a peptic ulcer. 6.ID: 311028939 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?  Contact the healthcare provider and complete a medication variance form.  Administer the Levaquin at 1300 and resume the 0900 schedule in the morning.  Notify the charge nurse and complete an incident report to explain the missed dose.  Give the missed dose at 1300 and change the schedule to administer daily at 1300. Correct 7.ID: 310953457 While instructing a male client's wife in the performance of passive range-of-motion exercises to his contracted shoulder, the nurse observes that she is holding his arm above and below the elbow. What nursing action should the nurse implement?  Acknowledge that she is supporting the arm correctly. Correct  Encourage her to keep the joint covered to maintain warmth.  Reinforce the need to grip directly under the joint for better support.  Instruct her to grip directly over the joint for better motion. 8.ID: 310978673 What is the most important reason for starting intravenous infusions in the upper extremities rather than the lower extremities of adults?  It is more difficult to find a superficial vein in the feet and ankles.  A decreased flow rate could result in the formation of a thrombosis. Correct  A cannulated extremity is more difficult to move when the leg or foot is used.  Veins are located deep in the feet and ankles, resulting in a more painful procedure. 9.ID: 310949430 The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?  Tell the UAP to use a larger cuff at the next scheduled assessment.  Reassess the client's blood pressure using a larger cuff. Correct  Have the unit educator review this procedure with the UAPs.  Teach the UAP the correct technique for assessing blood pressure. 10.ID: 310951961 A client is receiving a secondary infusion of a 300 mg dose medication q6 hour. The preparation arrives from the pharmacy diluted in 50 mL of 0.9% Sodium Chloride (NaCl). The nurse plans to administer the dose over 20 minutes. For how many mL/hour should the nurse program the infusion pump to deliver the secondary infusion? (Enter the numeric value only.) Correct Responses: "150" 11.ID: 310965943 Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?  That means you have derived the maximum benefit, and the heat can be removed.  Your blood vessels are becoming dilated and removing the heat from the site.  We will increase the temperature 5 degrees when the pad no longer feels warm.  The body's receptors adapt over time as they are exposed to heat. Correct 12.ID: 310955017 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?  If I exercise at least two times weekly for one hour, I will lower my cholesterol.  I need to avoid eating proteins, including red meat.  I will limit my intake of beef to 4 ounces per week. Correct  My blood level of low density lipoproteins needs to increase. 13.ID: 310985659 The UAPs working on a chronic neuro unit ask the nurse to help them determine the safest way to transfer an elderly client with left-sided weakness from the bed to the chair. What method describes the correct transfer procedure for this client?  Place the chair at a right angle to the bed on the client's left side before moving.  Assist the client to a standing position, then place the right hand on the armrest.  Have the client place the left foot next to the chair and pivot to the left before sitting.  Move the chair parallel to the right side of the bed, and stand the client on the right foot. Correct 14.ID: 310999015 An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?  Position the client on the right side of the bed in reverse Trendelenburg.  Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.  Reposition in a Sim's position with the client's weight on the anterior ilium. Correct  Raise the side rails on both sides of the bed and elevate the bed to waist level. 15.ID: 310949410 A client who is a Jehovah’s Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client’s beliefs?  Autopsy of the body is prohibited.  Blood transfusions are forbidden. Correct  Alcohol use in any form is not allowed.  A vegetarian diet must be followed. 16.ID: 310989373 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. Correct  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. 17.ID: 311023657 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 pounds. Using a drip factor of 60 gtt/ml, how many drops per minute should the client receive?  31 gtt/min.  62 gtt/min.  93 gtt/min.  124 gtt/min. Correct 18.ID: 310953413