Hesi Fundamentals Practice Exam

The nurse observes that a male client has removed the covering from an ice pack applied to his knee. what action should the nurse take first?
observe the appearance of the skin under the ice pack

The nurse mixes 50 mg of Nitride in 250 mL of D5W and plans to administer the solution at a rate of 5mcg/kg/min to a client weighing 182 pounds. using the drip factor of 60gtt/mL, how many drops per minute should the client receive
124 gtt/mL

The healthcare provider prescribes an IV infusion of 1,000 mL of LR with 30 units of piton to run in over 4 hours for a client who has just delivered a 10 pound infant by C-section. The tubing has been changed to a 20gtt/mL admin set. the nurse plans to set the flow rate at how many gtt/min?
83 gtt/min

which assessment date provides the most accurate determination of proper placement of a NGT?
examining a chest x-ray obtained after the tubing was inserted

three days following 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?
instruct the client that the stoma will become smaller when the initial swelling diminishes

a female client with a NGT attached to low suction states that she is nauseated. the nurse assesses that there has been no drainage through the NGT in the last two hours. what action should the nurse take first?
reposition the client on her side

a hospitalized male client is receiving NGT 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?
after clearing the tube with 30mL of air, check the pH of the fluid withdrawn from the tube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 should the nurse document that is most accurate?
is disoriented to place and time

a client with chronic kidney diseases CKD selects a scrambled egg for his breakfast. what action should the nurse take?
commend the client for selecting a hight biologic value protein

when assisting an 82 y.o. client to ambulate, it is important for the nurse to realize that the cent of gravity for an elderly person is the?
upper torso

in developing a plan of care for a client with dementia, the nurse should remember the confusion in the elderly?
often follows relocation to new surroundings

a postoperative client will need to perform daily dressing changes after discharge, which outcome statement best demonstrates the clients readiness to manage his wound care after discharge? the client…..
demonstrates the wound care procedure correctly

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 preoperative assessment?
“what vitamin and mineral supplements do you take?”

during the initial morning assessment, a male client denies dysuria but reports that his urine appears dark amber, which intervention should the nurse implement?
Encourage additional oral intake of juices and water

which intervention is most important for the nurse to implement for a male client who is experiencing urinary retention?
assess for bladder distention

a client with acute hemorrhagic anemia is to receive four units of packed RBC’s as rapidly as possible, which intervention is most important for the nurse to implement?
ensure the accuracy of the blood type match

a male client being discharged with a prescription for the bronchodilator theophylline tells the nurse that he understands he is to take three doses of the medication each day. since, at the time of discharge, timed-relate capsules are not available, which does schedule should the nurse advise the client to follow?
8 am, 4pm and Midnight

a client is to receive 10 mEq of KCl diluted in 250 mL of normal saline over 4 hours. at what rate should the nurse set the clients intravenous infusion pump?
63 mL/hour

when evaluation a clients plan of care, the nurse determines that a desired outcome was not achieved. which action should the nurse implement first?
note which actions were not implemented

Which snack food is best for the nurse to provide a client with myasthenia graves who is at risk for altered nutritional status?
chocolate pudding

the nurse is instructing a client with high cholesterol about diet and life stile modification. what comment from the client indicates that the teaching has been effective?
“i will limit my intake of beef to 4 ounces per week”

An obese male client discusses with the nurse his plans to begin a long-term weight loss region. in addition to dietary changes, he plans to begin an intensive aerobic exercise program 3-4 times a week and to take stress management classes. after praising the client for his decision, which instruction is most important for the nurse to provide?
“be sure to have a complete physical exam before beginning your planned exercise program”

the nurse is teaching a client proper use of an inhaler. when should the client administer the inhaler-delivered medication to demonstrated correct use of the inhaler?
during the inhalation

an IV infusion terbutaline sulfate 5mg in 500 mL of D5W, infusing at a rate of 30 mug/min. is prescribed for a client in premature labor. how many mL/hr should the nurse set the infusion pump?

the healer provider prescribes the diuretic metolazone (zaroxolyn) 7.5 mg po. zaroxolyn is available in 5mg tablets. how much should the nurse plan to administer
1 1/2 tablets

the healer provider prescribes furosemide (lasix) 15mg IV STAT. on hand is lasix 20mg/2mL. How many mL should the nurse administer
1.75 mL

Heparin 20,000 units in 500 mL D5W at 50 mL/hour has been infusing for 5 hours. how much heparin has the client received?
11,000 units

the nurse is caring for a client who is received 24-hour total parenteral nutrition (TPN) via a central line at 54 mL/hr. when initially assessing the client. the nurse notes that the TPN solution has run out and the next TPN solution is not available. what immediate action should the nurse take?
infuse 10% dextrose and water at 54 mL/hour

Exam 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 0.5cm in diameter. how should the nurse record this finding?
Localized red rash comprised of flat areas, pinpoint to 0.5 cm in diameter

At the time of the first dressing change the client refuses to look at her mastectomy incision. the nurse tells the client that the incision is healing well, but the client refuses to talk about it. what would be an appropriate response to this clients silence?
“it is OK if you don’t want to take about your surgery, i will be available when you are ready”

The healthcare provider prescribes morphine sulfate 4mg IM STAT. Morphine comes in 8 mg per ml. How many ml should the nurse administer? 0.5 ml. A hospitalized male client is receiving nasogastric tube feedings via a small-bore tube and a …

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 …

1. A 12-year-old female is seen by the school nurse after recently experiencing increasing difficulty sitting and paying attention in class, and increasingly illegible handwriting. The nurse observes that the child has protruding eyeballs and a staring expression. What action …

An elderly client with a fractured left hip is on strict bed rest. Which nursing measure is essential to the client’s nursing care? Gently lift the client when moving in to a desired position The nurse is administering medications through …

1.What is the rationale for using the nursing process in planning care for clients? A. As a scientific process to identify nursing diagnoses of a clients’ healthcare problems. B. To establish nursing theory that incorporates the biopsychosocial nature of humans. …

The nurse is planning care for the a client who has fourth degree midline laceration that occurred during vaginal delivery of an 8 pound 10 ounce infant. What intervention has the highest priority? A. Administer Prescribed stool softner B. Administer …

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