Hesi Fundamentals 2 Practice Questions
2023/2024
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 - ANSWER
Answer: a. observe the appearance of the skin under the ice pack
Rationale: the first action taken by the nurse should be to assess the skin for any possible thermal injury (a). If no injury to the skin has occurred, the nurse can take the other actions b,c,d as needed.The nurse mixes 50 mg of Nipride in 250mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. Using a drip factor of 60gtt/mL how many drops per minute should the client receive? 1 / 4
- 31 gtt/min
- 62 gtt/min
- 93 gtt/min
- 124 gtt/min - ANSWER Answer: d. 124 gtt/min
- 42 gtt/min
- 83 gtt/min
- 125 gtt/min
- 250 gtt/min - ANSWER Answer: b. 83 gtt/min
Rationale: d is the correct calculation: 182/2.2 = 82.73 kg 5mcg x 82.73 = 413.65 mcg/min.250/50,000mcg = 200 mcg/ml 413.65/200 = 2.07 mL 60 x 2.07 = 124.28 gtt/min The healthcare provider prescribes an IV infusion of 1,000mL Ringer's Lactate with 30 units of Pitocin to run in over 4 hours for a client who has just delivered a 10 pound infant by caesarean 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?
Rationale:
1000ml / 4 hours = 250 ml/hour 250ml/60 min = 4.1667ml/min 4.1667ml/min x 20 gtt/ml = 83.33 gtt/min 2 / 4
Which assessment data provides the most accurate determination of proper placement of a nasogastric tube?
- aspirating gastric contents to assure a pH value of 4 or less
- hearing air pass in the stomach after injecting air into the tubing
- examining a chest x-ray obtained after the tubing was inserted
- checking the remaining length of tubing to ensure that the correct length was
inserted - ANSWER Answer: c. examining a chest x-ray obtained after tubing was inserted
Rationale: both a and b are methods used to determine proper placement of NG
tubing. However, the best indicator is c.D is not an indicator of proper placement Three days following 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
- instruct the client that the stoma will become smaller when the initial swelling
- offer to contact a member of the local ostomy support group to help him with
time
diminishes
his concerns 3 / 4
- encourage the client to handle the stoma equipment to gain confidence with
the procedure - ANSWER Answer: b. instruct the client that the stoma will become smaller when the initial swelling diminishes
Rationale: postoperative swelling causes enlargement of the stoma. The nurse
can teach the client that the stoma will become smaller when the swelling is diminished (b). This will help reduce the client's anxiety and promote acceptance of the colostomy. (a) does not provide 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 NG tube the last 2 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 - ANSWER
Answer: b. reposition the client on her side
Rationale: the immediate priority is to determine if the tube is functioning
properly, which could 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 were successful, the client may require an antiemetic (d).
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