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Comprehensive Hesi Fundamentals Test 2024 Graded A
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Comprehensive Hesi Fundamentals Test 2024 Graded A
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8/20/24, 11:52 PM Comprehensive Hesi Fundamentals Test 2024 Graded AHesi Fundamentals Test 2023
1. The home health nurse visits an elderly female client who had a brain
attack threemonths 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 safetyissue. (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 stopthe 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 asbradycardia (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.
• 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 theknee 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
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joints are supported. After the knee is
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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 ofgloves (D). (A, B, and C) do not require gloves.
7. What action should the nurse implement to prevent the formation of a
sacral ulcerfor 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
alignmentand 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 ulcerformation. 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 isbeing 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 ace bandage may be used to cover both, but no
bandage should be put under it(B). The Unna's paste boot should be applied
from the foot and wrapped towards the knee (C). The Unna's paste boot acts
as a sterile dressing, and should not be removedq8h. Weekly removal is
reasonable (D).
9. The nurse is administering an intermittent infusion of an antibiotic to a
client whoseintravenous (IV) access is an antecubital saline lock. After the
nurse opens the roller clamp on the IV tubing, the alarm on the infusion
pump indicates an obstruction. What action should the nurse take first?
• Check for a blood return.
• Reposition the client's arm. Correct
• Remove the IV site dressing.
• Flush the lock with saline.
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