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NUR104 HESI Fundamentals Practice Exam
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Hesi review and answers for assignment week 8-9
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NUR104 HESI Fundamentals Practice Exam
The nurse observes that a male client has removed the covering form an ice pack
applied to his knee. What action should the nurse take first?
Answer: Observe the appearance of the skin under the ice pack.
The nurse mixes 50mg of Nipride in 250ml of D5W and plans to administer the solution
at a rate of 5mcg/kg/min to a client weighing 182lbs. Using a drip factor of 60gtt/ml, how
many drops per min should the client receive?
Answer: 124gtt/min
lbs to kg
182/2.2 = 82.73kg
Dosage for the client
5mcg X 82.73 =413mcg/min
mcg / ml
250/50000mcg =200 mcg/ml
2.07ml/min with a drip factor of 60gtt/ml
60 x 2.07 =124.28gtt/min
A healthcare provider prescribes an IV infusion of 1000ml of Ringer's Lactate with 30
units of Pitocin to run in over 4hrs for a client who has just delivered a 10lbs infant via
cesarean section. The tubing has been changed to a 20gtt/ml administration set. The
nurse plans to set the flow rate to how many gtt/min?
Answer: 83 gtt/min
20gtt/ml x 1000 ml/4hrs x 1hr/60mins = 83gtt/min
Which assessment data provides the most accurate determination of proper placement
of a nasogastric tube?
Answer: Chest x-ray obtained after insertion
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?
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Answer: Instruct the client that the stoma will become smaller when the initial swelling
diminishes
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?
A. Irrigate the nasogastric tube with sterile normal saline.
B. Reposition the client on her side.
C. Advance the nasogastric tube an additional five centimeters.
D. Administer an intravenous antiemetic prescribed for PRN use.
Answer: (B)Reposition the client on her side
A hospitalized male client is receiving nasogastric tube feeding 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?
Answer: After clearing the tube with 30ml 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?
Answer: Is disorientated to place and time
A client with chronic kidney disease (CKD) selects a scrambled egg for his breakfast.
What action should the nurse take?
Answer: Commend the client for selecting a high biological value protein.
When assisting an 82-year-old client to ambulate, it is important for the nurse to realize
that the center of gravity for an elderly person is the
A. Arms.
B. Upper torso.
C. Head.
D. Feet.
Answer: (B) Upper Torso
In developing a plan of care for a client with dementia, the nurse should remember that
confusion in the elderly
Answer: Often follows relocation to new surroundings
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A postoperative client will need to perform daily dressing changes after
discharge. Which outcome statement best demonstrates the client's readiness to
manage his wound care after discharge?
Answer: The client demonstrates the wound care procedure correctly.
A client who is 5'5" tall and weighs 200 pounds is scheduled for surgery the next day.
What question is most important for the nurse to include during the preoperative
assessment?
Answer: What vitamin and mineral supplements do you take?
During the initial morning assessment, a male client denies dysuria but reports that his
urine appears dark amber. Which intervention should the nurse implement?
A. Provide additional coffee on the client's breakfast tray.
B. Exchange the client's grape juice for cranberry juice.
C. Bring the client additional fruit at mid-morning.
D. Encourage additional oral intake of juices and water.
Answer: (D)Encourage additional oral intake of juices and water.
Which intervention is most important for the nurse to implement for a male client who is
experiencing urinary retention?
A. Apply a condom catheter.
B. Apply a skin protectant.
C. Encourage increased fluid intake.
D. Assess for bladder distention.
Answer: (D)Assess for bladder distention.
A client with acute hemorrhagic anemia is to receive four units of packed RBCs as
rapidly as possible. Which intervention is most important for the nurse to implement?
Answer: Ensure the accuracy of the blood type match.
A male client is being discharged with a prescription for the bronchodilator theophylline
tells the nurse that he understands he is to take three doses of the medication each day.
Since, at the time of discharge, timed-release capsules are not available, which dosing
schedule should the nurse advise the client to follow?
Answer: 8am, 4pm, midnight
A client is to receive 10mEq of KCL diluted in 250ml of normal saline over 4hrs. At what
rate should the nurse set the clients IV infusion pump?
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