Hesi Fundamentals Practice Test (70 Q&A)
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 Ans:- 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 Ans:- 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 Ans:- 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 Ans:- A
Category | Testbanks |
Comments | 0 |
Rating | |
Sales | 0 |