Exam (elaborations)
HESI FUNDAMENTALS PRACTICE EXAM WITH COMPLETE SOLUTION.
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HESI FUNDAMENTALS PRACTICE EXAM WITH COMPLETE SOLUTION.
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HESI FUNDAMENTALS PRACTICE EXAM WITHCOMPLETE SOLUTION
The ,nurse ,observes ,that ,a ,male ,client ,has ,removed ,the ,covering ,from ,an ,ice ,park ,applied ,to ,his ,kne
e. ,What ,action ,should ,the ,nurse ,take ,first? ,
A. ,Observe ,the ,appearance ,of ,the ,skin ,under ,the ,ice ,pack.
B. ,Instruct ,the ,client ,regarding ,the ,need ,for ,the ,covering.
C. ,Reapply ,the ,covering ,after ,filling ,with ,fresh ,ice.
D. ,Ask ,the ,client ,how ,long ,the ,ice ,was ,applied ,to ,the ,skin. ,- ,(correct ,answer) ,-
Observe ,the ,appearance ,of ,the ,skin ,under ,the ,ice ,pack ,
(The ,first ,action ,taken ,by ,the ,nurse ,should ,be ,to ,assess ,the ,skin ,for ,any ,possible ,thermal ,injury. ,If ,n
o ,injury ,to ,the ,skin ,has ,occurred, ,the ,nurse ,can ,take ,the ,other ,actions.)
The ,nurse ,mixes ,50 ,mg ,of ,Nipride ,in ,250 ,mL ,of ,D5W ,and ,plans ,to ,administer ,the ,solution ,at ,a ,rate ,
of ,5
,mcg/kg/min ,to ,a ,client ,weighting ,182 ,lbs. ,Using ,a ,drip ,factor ,of ,60
,gtt/mL, ,how ,many ,drops ,per ,minute ,should ,the ,client ,receive? ,- ,(correct ,answer) ,-124 ,gtt/min
The ,healthcare ,provider ,prescribes ,an ,IV ,infusion ,of ,1000 ,ml ,of ,Ringer's ,Lactate ,w/ ,30 ,units ,of ,Pitoc
in ,to ,run ,in ,over ,4 ,hours ,for ,a ,client ,who ,has ,just ,delivered ,a ,10 ,pound ,infant ,by ,cesarean ,section. ,
The ,tubing ,has ,been ,changed ,to ,a ,20
,gtt/ml ,administration ,set. ,The ,nurse ,plans ,to ,set ,the ,flow ,rate ,at ,how ,many ,gtt/min? ,- ,
(correct ,answer) ,-83 ,gtt/min
Which ,assessment ,data ,provides ,the ,most ,accurate ,determination ,of ,proper ,placement ,of ,a ,nasogas
tric ,tube? ,- ,(correct ,answer) ,-Examining ,a ,chest ,x-ray ,obtained ,after ,the ,tubing ,was ,inserted
Three ,days ,following ,a ,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?
A. ,Reassure ,the ,client ,that ,he ,will ,become ,accustomed ,to ,the ,stoma ,appearance ,in ,time. ,
,B. ,Instruct ,the ,client ,that ,the ,stoma ,will ,become ,much ,smaller ,when ,the ,initial ,swelling ,diminishes. ,
C. ,Offer ,to ,contact ,a ,member ,of ,the ,local ,ostomy ,support ,group ,to ,help ,him ,with ,his ,concerns.
D. ,Encourage ,the ,client ,to ,handle ,the ,stoma ,equipment ,to ,gain ,confidence ,with ,the ,procedure. ,- ,
(correct ,answer) ,-
B. ,Instruct ,the ,client ,that ,the ,stoma ,will ,become ,smaller ,when ,the ,initial ,swelling ,diminishes ,
(Postoperative ,swelling ,causes ,enlargement ,of ,the ,stoma. ,The ,nurse ,can ,teach ,the ,client ,that ,the ,st
oma ,will ,become ,smaller ,when ,swelling ,is ,diminished ,
(B). ,This ,will ,help ,reduce ,the ,client's ,anxiety ,and ,promote ,acceptance ,of ,the ,colostomy. ,
(A) ,does ,not ,provide ,helpful ,teaching ,or ,support. ,
(C) ,is ,a ,useful ,action, ,and ,may ,be ,taken ,after ,the ,nurse ,provides ,pertinent ,teaching. ,The ,client ,is ,no
t ,yet ,demonstrating ,readiness ,to ,learn ,colostomy ,care. ,(D)
A ,female ,client ,with ,a ,nasogastric ,tube ,attached ,to ,low ,suction ,states ,that ,she ,is ,nauseated. ,The ,nu
rse ,assesses ,that ,there ,has ,been ,no ,drainage ,through ,the ,nasogastric ,tube ,in ,the ,last ,two ,hours. ,W
hat ,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. ,- ,(correct ,answer) ,-
B. ,Reposition ,the ,client ,on ,her ,side. ,
(The ,immediate ,priority ,is ,to ,determine ,if ,the ,tube ,is ,functioning ,correctly, ,which ,would ,then ,reliev
e ,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))
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 ,HCP.
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. ,- ,
(correct ,answer) ,-
C. ,After ,clearing ,the ,tube ,with ,30 ,ml ,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 ,shoul
d ,the ,nurse ,document ,that ,is ,most ,accurate?
A. ,demonstrates ,loss ,of ,remote ,memory
B. ,exhibits ,expressive ,dysphasia
C. ,has ,a ,diminished ,attention ,span
D. ,is ,disoriented ,to ,place ,and ,time ,- ,(correct ,answer) ,-D. ,is ,disoriented ,to ,place ,and ,time ,(The ,client
,is ,exhibiting ,disorientation ,(D). ,
(A) ,refers ,to ,memory ,of ,the ,distant ,past. ,The ,client ,is ,able ,to ,express ,himself ,without ,difficulty ,
(B), ,and ,does ,not ,demonstrate ,diminished ,attention ,span. ,(C).
A ,client ,with ,chronic ,kidney ,disease ,
(CKD) ,selects ,a ,scrambled ,egg ,for ,his ,breakfast. ,What ,action ,should ,the ,nurse ,take?
A. ,Commend ,the ,client ,for ,selecting ,a ,high ,biologic ,value ,protein.
B. ,Remind ,the ,client ,that ,protein ,in ,the ,diet ,should ,be ,avoided.
C. ,Suggest ,that ,the ,client ,also ,select ,orange ,juice, ,to ,promote ,absorption.
D. ,Encourage ,the ,client ,to ,attend ,classes ,on ,dietary ,management ,of ,CKD. ,- ,(correct ,answer) ,-
A. ,Commend ,the ,client ,for ,selecting ,a ,high ,biologic ,value ,protein. ,(Foods ,such ,as ,eggs ,and ,milk ,
(A) ,are ,high ,biologic ,proteins ,which ,are ,allowed ,because ,they ,are ,complete ,proteins ,and ,supply ,the ,
essential ,amino ,acids ,that ,are ,necessary ,for ,growth ,and ,cell ,repair. ,Orange ,juice ,is ,rich ,in ,potassium
,and ,should ,not ,be ,encouraged. ,The ,client ,has ,made ,a ,good ,diet ,choice ,so ,(D) ,is ,not ,necessary.)
When ,assisting ,an ,82 ,year ,old ,client ,to ,ambulate, ,it ,is ,important ,for ,the ,nurse ,to ,realize ,that ,the ,ce
nter ,of ,gravity ,for ,an ,elderly ,person ,is ,the-- ,- ,(correct ,answer) ,-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 ,knee
s, ,hips, ,and ,elbows ,flex. ,This ,stooped ,posture ,results ,in ,the ,upper ,torso ,becoming ,the ,center ,of ,gra
vity ,for ,older ,persons.)
In ,developing ,a ,plan ,of ,care ,for ,a ,client ,with ,dementia, ,the ,nurse ,should ,remember ,that ,confusion ,i
n ,the ,elderly ,
A. ,is ,to ,be ,expected, ,and ,progresses ,with ,age
B. ,often ,follows ,relocation ,to ,new ,surroundings
C. ,is ,a ,result ,of ,irreversible ,brain ,pathology ,
D. ,can ,be ,prevented ,with ,adequate ,sleep ,- ,(correct ,answer) ,-
B. ,often ,follows ,relocation ,to ,new ,surroundings ,(Relocation ,
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