Hesi Fundamentals Practice Questions
Fundamentals Hesi
1. The home health nurse visits an elderly female client who had a brain attack three
months ago and is now able to ambulate with the assistance of a quad cane. Which
assessment finding has the greatest implications for this client's care?
• The husband, who is the caregiver, begins to weep when the nurseasks how
he is doing.
• The client tells the nurse that she does not have much of an appetite today.
• The nurse notes that there are numerous scatter rugs throughout the house.
Correct
• The client's pulse rate is 10 beats higher than it was at the last visit one week
ago.
Scatter rugs (C) pose a safety hazard because the client can trip on them when
ambulating, so this finding has the greatest significance in planning this client's care.
Psychological support of the caregiver (A) is a less acute need than that of client
safety. The nurse needs to obtain more information about (B), but this is not a safety
issue. (D) is not a significant increase, and additional assessment might provide
information about the reason for the increase (anxiety, exercise, etc.).
2. The nurse is digitally removing a fecal impaction for a client. The nurse should stop
the procedure and take corrective action if which client reaction is noted?
• Temperature increases from 98.8° to 99.0° F.
• Pulse rate decreases from 78 to 52 beats/min. Correct • Respiratory rate
increases from 16 to 24 breaths/min.
• Blood pressure increases from 110/84 to 118/88 mm/Hg.
Parasympathetic reaction can occur as a result of digital stimulation of the anal
sphincter, which should be stopped if the client experiences a vagal response, such
as bradycardia (B). (A, C, and D) do not warrant stopping the procedure.
3. The nurse is providing passive range of motion (ROM) exercises to the hip and
knee for a client who is unconscious. After supporting the client's knee with one
hand, what action should the nurse take next?
• Raise the bed to a comfortable working level.
• Bend the client's knee.
• Move the knee toward the chest as far as it will go.
• Cradle the client's heel. Correct
Passive ROM exercise for the hip and knee is provided by supporting the joints of the
knee and ankle (D) and gently moving the limb in a slow, smooth, firm but gentle
manner. (A) should be done before the exercises are begun to prevent injury to the
nurse and client. (B) is carried out after both joints are supported. After the knee is
bent, then the knee is moved toward the chest to the point of resistance (C) two or
three times.
4. A client who has moderate, persistent, chronic neuropathic pain due to diabetic
neuropathy takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily. If Step
2 of the World Health Organization (WHO) pain relief ladder is prescribed, which
drug protocol should be implemented?
• Continue gabapentin. Correct • Discontinue ibuprofen.
• Add aspirin to the protocol.
• Add oral methadone to the protocol.
Based on the WHO pain relief ladder, adjunct medications, such as gabapentin
(Neurontin), an antiseizure medication, may be used at any step for anxiety and pain
management, so (A) should be implemented. Nonopiod analgesics, such as
ibuprofen (A) and aspirin (C) are Step 1 drugs. Step 2 and 3 include opioid narcotics
(D), and to maintain freedom from pain, drugs should be given around the clock
rather than by the client s PRN requests.
5. The nurse is preparing to irrigate a client's indwelling urinary catheter using an
open technique. What action should the nurse take after applying gloves?
• Empty the client's urinary drainage bag.
• Draw up the irrigating solution into the syringe. Correct • Secure the client's
catheter to the drainage tubing.
• Use aseptic technique to instill the irrigating solution.To irrigate an indwelling
urinary catheter, the nurse should first apply gloves, then draw up the irrigating
solution into the syringe (B). The syringe is then attached to the catheter and the
fluid instilled, using aseptic technique (D). Once the irrigating solution is instilled,
the client's catheter should be secured to the drainage
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