1. An elderly client with a fractured D. Gently lift the client when moving
left hip is on strict bedrest. Which into a desired position.
nursing measure is essential to the
client's nursing care? To avoid shearing forces when reposi-
tioning, the client should be lifted gen-
A. Massage any reddened areas for tly across a surface (D). Reddened
at least five minutes. areas should not be massaged (A)
B. Encourage active range of mo- since this may increase the damage
tion exercises on extremities. to already traumatized skin. To control
C. Position the client laterally, pain and muscle spasms, active range
prone, and dorsally in sequence. of motion (B) may be limited on the
D. Gently lift the client when mov- affected leg. The position described in
ing into a desired position. (C) is contraindicated for a client with
a fractured left hip.
2. The nurse is administering medica- B. Flush the tube with water.
tions through a nasogastric tube
(NGT) which is connected to suc- The NGT should be flushed before,
tion. After ensuring correct tube after and in between each medica-
placement, what action should the tion administered (B). Once all med-
nurse take next? ications are administered, the NGT
should be clamped for 20 minutes (A).
A. Clamp the tube for 20 minutes. (C and D) may be implemented only
B. Flush the tube with water. after the tubing has been flushed.
C. Administer the medications as
prescribed.
D. Crush the tablets and dissolve in
sterile water.
3. A client who is in hospice care A. Give an around-the-clock schedule
complains of increasing amounts for administration of analgesics.
of pain. The healthcare provider
prescribes an analgesic every four The most effective management
hours as needed. Which action of pain is achieved using an
should the nurse implement? around-the-clock schedule that pro-
vides analgesic medications on a reg-
A. Give an around-the-clock sched- ular basis (A) and in a timely manner.
ule for administration of anal- Analgesics are less effective if pain
gesics. persists until it is severe, so an anal-
, HESI PN Fundamentals
l
B. Administer analgesic medica- gesic medication should be adminis-
tion as needed when the pain is tered before the client's pain peaks
severe. (B). Providing comfort is a priority for
C. Provide medication to keep the the client who is dying, but sedation
client sedated and unaware of stim- that impairs the client's ability to in-
uli. teract and experience the time before
D. Offer a medication-free period so life ends should be minimized (C). Of-
that the client can do daily activi- fering a medication-free period allows
ties. the serum drug level to fall, which is
not an effective method to manage
chronic pain (D).
4. When assessing a client with wrist A. Loosen the right wrist restraint.
restraints, the nurse observes that
the fingers on the right hand are The priority nursing action is to restore
blue. What action should the nurse circulation by loosening the restraint
implement first? (A), because blue fingers (cyanosis)
indicates decreased circulation. (C
A. Loosen the right wrist restraint. and D) are also important nursing in-
B. Apply a pulse oximeter to the terventions, but do not have the priori-
right hand. ty of (A). Pulse oximetry (B) measures
C. Compare hand color bilaterally. the saturation of hemoglobin with oxy-
D. Palpate the right radial pulse. gen and is not indicated in situations
where the cyanosis is related to me-
chanical compression (the restraints).
5. The nurse is assessing the nu- B. A lactating woman nursing her
tritional status of several clients. 3-day-old infant.
Which client has the greatest nutri-
tional need for additional intake of A lactating woman (B) has the great-
protein? est need for additional protein intake.
(A, C, and D) are all conditions that
A. A college-age track runner with a require protein, but do not have the
sprained ankle. increased metabolic protein demands
B. A lactating woman nursing her of lactation.
3-day-old infant.
C. A school-aged child with Type 2
diabetes.
, HESI PN Fundamentals
l
D. An elderly man being treated for
a peptic ulcer.
6. A client is in the radiology depart- D. Give the missed dose at 1300 and
ment at 0900 when the prescription change the schedule to administer
levofloxacin (Levaquin) 500 mg IV daily at 1300.
q24h is scheduled to be adminis-
tered. The client returns to the unit
To ensure that a therapeutic level of
at 1300. What is the best interven- medication is maintained, the nurse
tion for the nurse to implement? should administer the missed dose as
soon as possible, and revise the ad-
A. Contact the healthcare provider ministration schedule accordingly to
and complete a medication vari- prevent dangerously increasing the
ance form. level of the medication in the blood-
B. Administer the Levaquin at 1300 stream (D). The nurse should docu-
and resume the 0900 schedule in ment the reason for the late dose, but
the morning. (A and C) are not warranted. (B) could
C. Notify the charge nurse and com- result in increased blood levels of the
plete an incident report to explain drug.
the missed dose.
D. Give the missed dose at 1300
and change the schedule to admin-
ister daily at 1300.
7. While instructing a male client's A. Acknowledge that she is supporting
wife in the performance of passive the arm correctly.
range-of-motion exercises to his
contracted shoulder, the nurse ob- The wife is performing the passive
serves that she is holding his arm ROM correctly, therefore the nurse
above and below the elbow. What should acknowledge this fact (A). The
nursing action should the nurse im- joint that is being exercised should
plement? be uncovered (B) while the rest of
the body should remain covered for
A. Acknowledge that she is sup- warmth and privacy. (C and D) do not
porting the arm correctly. provide adequate support to the joint
B. Encourage her to keep the joint while still allowing for joint movement.
covered to maintain warmth.
C. Reinforce the need to grip direct-
ly under the joint for better support.
, HESI PN Fundamentals
l
D. Instruct her to grip directly over
the joint for better motion.
8. What is the most important reason B. A decreased flow rate could result
for starting intravenous infusions in the formation of a thrombosis.
in the upper extremities rather than
the lower extremities of adults? Venous return is usually better in
the upper extremities. Cannulation of
A. It is more difficult to find a super- the veins in the lower extremities in-
ficial vein in the feet and ankles. creases the risk of thrombus forma-
B. A decreased flow rate could re- tion (B) which, if dislodged, could be
sult in the formation of a thrombo- life-threatening. Superficial veins are
sis. often very easy (A) to find in the feet
C. A cannulated extremity is more and legs. Handling a leg or foot with
difficult to move when the leg or an IV (C) is probably not any more
foot is used. difficult than handling an arm or hand.
D. Veins are located deep in the Even if the nurse did believe moving a
feet and ankles, resulting in a more cannulated leg was more difficult, this
painful procedure. is not the most important reason for
using the upper extremities. Pain (D)
is not a consideration.
9. The nurse observes an unlicensed B. Reassess the client's blood pres-
assistive personnel (UAP) taking a sure using a larger cuff.
client's blood pressure with a cuff
that is too small, but the blood pres- The most important action is to ensure
sure reading obtained is within the that an accurate BP reading is ob-
client's usual range. What action is tained. The nurse should reassess the
most important for the nurse to im- BP with the correct size cuff (B). Re-
plement? assessment should not be postponed
(A). Though (C and D) are likely indi-
A. Tell the UAP to use a larger cuff cated, these actions do not have the
at the next scheduled assessment. priority of (B).
B. Reassess the client's blood
pressure using a larger cuff.
C. Have the unit educator review
this procedure with the UAPs.
D. Teach the UAP the correct tech-
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