HESI FUNDAMENTALS PRACTICE

HESI FUNDAMENTALS PRACTICE

EXAM The nurse observes that a male client has removed the covering from an ice park 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

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. If no injury to the skin has occurred, the nurse can take the other actions.) 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 weighting 182 lbs. Using a drip factor of 60 gtt/mL, how many drops per minute should the client receive? - CORRECT ANSWER 124 gtt/min 1 / 4

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 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 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 (B). This will help reduce the client's anxiety and promote acceptance of the colostomy. (A) does not provide 2 / 4

helpful teaching or support. (C) is a useful action, and may be taken after the nurse provides pertinent teaching. The client is not yet demonstrating readiness to learn colostomy care. (D) 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 (B) should be attempted first, followed by (A and C), unless either of these interventions is contraindicated. If these measures are unsuccessful, the client may require an antiemetic (D)) 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. 3 / 4

• 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.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
• has a diminished attention span
• is disoriented to place and time - CORRECT ANSWER D. is disoriented to

place and time (The client is exhibiting disorientation (D). (A) refers to memory of the distant past. The client is able to express himself without difficulty (B), and does not demonstrate diminished attention span. (C).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. -

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

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