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 ...
,ALL HESI Fundamentals Exam Test Bank updated 2024
HESI Fundamentals Exam, Answered
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 Answer: 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 Answer: 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 Answer: 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 Answer: A
The nurse is assessing the nutritional status of several clients. Which client has the
greatest nutritional need for additional intake of protein?
A. A college-age track runner with a sprained ankle.
B. A lactating woman nursing her 3-day-old infant.
C. A school-aged child with Type 2 diabetes.
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