Spring HESI 2| UPDATED JULY 2024
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Exa...
Which assessment data would provide the most accurate determination of proper
placement of a nasogastric tube?
A) Aspirating gastric contents to assure a pH value of 4 or less.
B) Hearing air pass in the stomach after injecting air into the tubing.
C) Examining a chest x-ray obtained after the tubing was inserted.
D) Checking the remaining length of tubing to ensure that the correct length was
inserted. **** C) Examining a chest x-ray obtained after the tubing was inserted
Both (A and B) are methods used to determine proper placement of the NG tubing.
However, the best indicator that the tubing is properly placed is (C). (D) is not an
indicator of proper placement
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 **** B) Upper torso
The center of gravity for adults is the hips. However, as the person grows older, a
stooped posture is common because of the changes from osteoporosis and normal
bone degeneration, and the knees, hips, and elbows flex. This stooped posture results
in the upper torso (B) becoming the center of gravity for older persons. Although (A) is a
part, or an extension of the upper torso, this is not the best and most complete answer.
Which action is most important for the nurse to implement when donning sterile gloves?
A) Maintain thumb at a ninety degree angle.
B) Hold hands with fingers down while gloving.
C) Keep gloved hands above the elbows.
D) Put the glove on the dominant hand first. **** C) Keep gloved hands above the
elbows
Gloved hands held below waist level are considered unsterile (C). (A and B) are not
essential to maintaining asepsis. While it may be helpful to put the glove on the
dominant hand first, it is not necessary to ensure asepsis (D).
,An adult male client with a history of hypertension tells the nurse that he is tired of
taking antihypertensive medications and is going to try spiritual meditation instead.
What should be the nurse's first response?
A) It is important that you continue your medication while learning to meditate.
B) Spiritual meditation requires a time commitment of 15 to 20 minutes daily.
C) Obtain your healthcare provider's permission before starting meditation.
D) Complementary therapy and western medicine can be effective for you. **** A) It
is important that you continue your medication while learning to meditate
The prolonged practice of meditation may lead to a reduced need for antihypertensive
medications. However, the medications must be continued (A) while the physiologic
response to meditation is monitored. (B) is not as important as continuing the
medication. The healthcare provider should be informed, but permission is not required
to meditate (C). Although it is true that this complimentary therapy might be effective
(D), it is essential that the client continue with antihypertensive medications until the
effect of meditation can be measured
The nurse plans to obtain health assessment information from a primary source. Which
option is a primary source for the completion of the health assessment?
A) Client.
B) Healthcare provider.
C) A family member.
D) Previous medical records **** A) Client
A primary source of information for a health assessment is the client (A). (B, C, and D)
are considered secondary sources about the client's health history, but other details,
such as subjective data, can only be provided directly from the client.
The nurse is instructing a client with high cholesterol about diet and life style
modification. What comment from the client indicates that the teaching has been
effective?
A) If I exercise at least two times weekly for one hour, I will lower my cholesterol.
B) I need to avoid eating proteins, including red meat.
C) I will limit my intake of beef to 4 ounces per week.
D) My blood level of low density lipoproteins needs to increase. **** C) I will limit my
intake of beef to 4 ounces per week
Limiting saturated fat from animal food sources to no more than 4 ounces per week (C)
is an important diet modification for lowering cholesterol. To be effective in reducing
cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per
week (A). Red meat and all proteins do not need to be eliminated (B) to lower
cholesterol, but should be restricted to lean cuts of red meat and smaller portions (2-
ounce servings). The low density lipoproteins (D) need to decrease rather than increase
,Examination of a client complaining of itching on his right arm reveals a rash made up of
multiple flat areas of redness ranging from pinpoint to 0.5 cm in diameter. How should
the nurse record this finding?
A) Multiple vesicular areas surrounded by redness, ranging in size from 1 mm to 0.5 cm.
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter.
C) Several areas of red, papular lesions from pinpoint to 0.5 cm in size.
D) Localized petechial areas, ranging in size from pinpoint to 0.5 cm in diameter. ****
B) Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter
Macules are localized flat skin discolorations less than 1 cm in diameter. However,
when recording such a finding the nurse should describe the appearance (B) rather than
simply naming the condition. (A) identifies vesicles -- fluid filled blisters -- an incorrect
description given the symptoms listed. (C) identifies papules -- solid elevated lesions,
again not correctly identifying the symptoms. (D) identifies petechiae -- pinpoint red to
purple skin discolorations that do not itch, again an incorrect identification
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?
A) What is your daily calorie consumption?
B) What vitamin and mineral supplements do you take?
C) Do you feel that you are overweight?
D) Will a clear liquid diet be okay after surgery? **** A) What is your daily calorie
consumption?
Vitamin and mineral supplements (B) may impact medications used during the operative
period. (A and C) are appropriate questions for long-term dietary counseling. The nature
of the surgery and anesthesia will determine the need for a clear liquid diet (D), rather
than the client's preference
The nurse is performing nasotracheal suctioning. After suctioning the client's trachea for
fifteen seconds, large amounts of thick yellow secretions return. What action should the
nurse implement next?
A) Encourage the client to cough to help loosen secretions.
B) Advise the client to increase the intake of oral fluids.
C) Rotate the suction catheter to obtain any remaining secretions.
D) Re-oxygenate the client before attempting to suction again. **** D) Re-oxygenate
the client before attempting to suction again
Suctioning should not be continued for longer than ten to fifteen seconds, since the
client's oxygenation is compromised during this time (D). (A, B, and C) may be
performed after the client is re-oxygenated and additional suctioning is performed.
, A hospitalized male client is receiving nasogastric tube feedings 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?
A) Record the coughing incident. No further action is required at this time.
B) Stop the feeding, explain to the family why it is being stopped, and notify the
healthcare provider.
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the
tube.
D) Inject 30 ml of air into the tube while auscultating the epigastrium for gurgling. ****
C) After clearing the tube with 30 ml of air, check the pH of fluid withdrawn from the tube
Coughing, vomiting, and suctioning can precipitate displacement of the tip of the small
bore feeding tube upward into the esophagus, placing the client at increased risk for
aspiration. Checking the sample of fluid withdrawn from the tube (after clearing the tube
with 30 ml of air) for acidic (stomach) or alkaline (intestine) values is a more sensitive
method for these tubes, and the nurse should assess tube placement in this way prior to
taking any other action (C). (A and B) are not indicated. The auscultating method (D)
has been found to be unreliable for small-bore feeding tubes.
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. **** B) Reposition
the client on her side
The immediate priority is to determine if the tube is functioning correctly, which would
then relieve the client's nausea. The least invasive intervention, (B), should be
attempted first, followed by (A and C), unless either of these interventions is
contraindicated. If these measures are unsuccessful, the client may require an
antiemetic (D).
The UAPs working on a chronic neuro unit ask the nurse to help them determine the
safest way to transfer an elderly client with left-sided weakness from the bed to the
chair. What method describes the correct transfer procedure for this client?
A) Place the chair at a right angle to the bed on the client's left side before moving.
B) Assist the client to a standing position, then place the right hand on the armrest.
C) Have the client place the left foot next to the chair and pivot to the left before sitting.
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