Hesi Fundamentals 2019 Exam

Questions

HESI FUNDAMENTALS 2019 EXAM

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 nurse asks 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.

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 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 tubing (C). The

urinary drainage bag can be emptied (A) whenever intake and output measurement is

indicated, and the instilled irrigating fluid can be subtracted from the output at that time.

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6. Which client care requires the nurse to wear barrier gloves as required by the

protocol for Standard Precautions?

 Removing the empty food tray from a client with a urinary catheter.

 Washing and combing the hair of a client with a fractured leg in traction.

 Administering oral medications to a cooperative client with a wound infection.

 Emptying the urinary catheter drainage bag for a client with Alzheimer's

disease. Correct

Possible contact with body secretions, excretions, or broken skin is an indication for

wearing barrier (nonsterile) gloves. Emptying a urine drainage bag requires the use of

gloves (D). (A, B, and C) do not require gloves.

7. What action should the nurse implement to prevent the formation of a sacral ulcer

for a client who is immobile?

 Maintain in a lateral position using protective wrist and vest devices.

 Position prone with a small pillow below the diaphragm. Correct

 Raise the head and knee gatch when lying in a supine position.

 Transfer into a wheelchair close to the nurse's station for observation.

The prone position (B) using a small pillow below the diaphragm maintains alignment

and provides the best pressure relief over the sacral bony prominence. Using protective

(restraining) devices (A) is not indicated. Raising the head and bed gatch (C) may

reduce shearing forces due to sliding down in bed, but it interferes with venous return

from the legs and places pressure on the sacrum, predisposing to ulcer formation.

Sitting in a wheelchair (D) places the body weight over the ischial tuberosities and

predisposes to a potential pressure point.

8. What intervention should the nurse include in the plan of care for a client who is

being treated with an Unna's paste boot for leg ulcers due to chronic venous

insufficiency?

 Check capillary refill of toes on lower extremity with Unna's paste boot.

Correct

 Apply dressing to wound area before applying the Unna's paste boot.

 Wrap the leg from the knee down towards the foot.

 Remove the Unna's paste boot q8h to assess wound healing.

The Unna's paste boot becomes rigid after it dries, so it is important to check distally for

adequate circulation (A). Kerlix is often wrapped around the outside of the boot and an

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