HESI FUNDAMENTALS PRACTICE

HESI FUNDAMENTALS PRACTICE

TEST / FINAL EXAM 2 (NCLEX)

An adult is now alert and oriented following abdominal surgery. What position is most appropriate for the client?

• Semi-Fowler's
• Prone
• Supine
• Sim's - A

This position allows for greater thoracic expansion and puts less pressure on the suture line

Following a craniotomy, the nurse positioned a client in low fowler's for which reason?

• To promote comfort
• To promote drainage from operation site
• To promote thoracic expansion
• To prevent circulatory overload - B

The nurse is caring for a woman who had a CVA and has right-sided hemiplegia.Which action is least appropriate?

• Performing ROM exercise when bathing her
• Changing her position every two hours
• Suctioning the client supine and pulling the bed sheets tightly across her feet
• Placing her in the prone position for one hour three times a day - C

The sheets should not be drawn tightly across the feet as this may cause foot drop

The nurse is to help their client with right-sided hemiplegia get up into the wheelchair. How should the nurse place the wheelchair?

• On the left side of the bed facing the foot of the bed
• On the right side of the bed facing the head of the bed
• Perpendicular to the bed on the right side
• Facing the bed in the left side of the bed - A

The client can then stand on the unaffected foot and pivot to sit down

When caring for a client in hemorrhagic shock, how should the nurse position the client?

• Flat in bed with legs elevated
• Flat in bed
• Trendelenburg position
• Semi-Fowler's position - A

Mr. Landon is to have a tracheostomy performed. What is the top nursing priority?

• Shave the neck
• Establish a means of communication
• Insert a Foley catheter
• Start an IV - B

Mr. Landon is to have a tracheostomy performed. Which nursing action is essential during tracheal suctioning?

• Using a lubricant such as petroleum jelly
• Administering 100% oxygen before and after suctioning
• Making sure that the suction catheter is open or on during insertion
• Assisting the client to assume a supine position during suctioning - B--To prevent

hypoxia

Mr. Landon is to have a tracheostomy performed. Which of the following actions is most appropriate for the nurse to take when suctioning the tracheostomy?

• Use sterile tube each time and suction for 30 seconds
• Use sterile technique and turn the suction off as the catheter is introduced
• Use clean technique and suction for 10 seconds
• Discard the catheter at the end of every shift - B

Mr. Landon is to have a tracheostomy performed. While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?

• Suction deeper to pick up secretions
• Gently withdraw suction tubing to allow suction or coughing out of mucous
• Remove the suction as quickly as possible
• Put the suction in and out several times to pick up secretions - D

During the suctioning of a tracheostomy tube, the catheter appears to attach to the tracheal walls and creates a pulling sensation. What is the best action for the nurse to take?

• Release the suction by opening the vent
• Continue suctioning to remove obstruction
• Increase the pressure
• Suction deeper - A

Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?

• Use sterile technique when applying the dressing
• Leave the compresses on the area continuously, pouring warm solution on the

area when it cools down

• Alternate warm compressed with cold ones
• Apply wet dressing, cover with dry dressing - A

The day after surgery in which a colostomy was performed, the client says "I know the doctor did not really do a colostomy". The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery, with nursing action is indicated at this time?

• Agree with the client until he is ready to accept the colostomy
• Say "It must be difficult to have this kind of surgery"
• Force the client to look at his colostomy
• Ask the surgeon to explain the surgery to the client - B

The nurse is preparing to insert an indwelling catheter. What type of technique should the nurse observe to perform this procedure?

• Clean technique
• Medical Asepsis
• Isolation Protocol
• Sterile Technique - D

. The nurse is performing a urethral catheterization on a female. After separating the labia, where would the nurse observe the urethral meatus?

• Between the vaginal orifice and the anus
• Between the clitoris and the vaginal orifice
• Just above the clitoris
• Within the vaginal canal - B

The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?

• Remove the catheter and reinsert it with the client positioned differently
• Try a straight catheter instead
• Try a smaller catheter
• Discontinue the procedure and notify the physician - D-- This may indicate an

obstruction

After insertion of the indwelling catheter, how should the nurse position the drainage container?

• With the drainage tubing taut to maintain maximum suction on the urinary bladder.
• Lower than the bladder to maintain a constant downward flow of urine from the

bladder.

• At the head of the bed for easy and accurate measurement of urine.
• Beside the patient in his bed to avoid embarrassment. - B

An adult had an indwelling catheter removed, after she voids for the first time, the nurse catheterizes her as ordered and obtained 200 cc of urine. What is the best

interpretation of this finding? The client:

• Is voiding normally
• Has urinary retention
• Has developed renal failure
• Needs an indwelling catheter - B

The nurse plans to foster a therapeutic relationship with the patient utilizing

therapeutic techniques of communication. It is most important that the nurse:

• Work on establishing a friendship with the patient
• Use humour to diffuse emotionally charged topics of discussion
• Sympathize with the patient when the patient shares sad feelings
• Demonstrate respect when discussing emotionally charged topics - D

The main purpose of the working phase of the nurse-patient relationship is to:

• Establish a formal or informal contract that adheres to the patient's problems.
• Implement nursing interventions that are designed to achieve expected patient

outcome.

• Develop rapport and trust so the patient feels protected and initial plan can be

identified.

• Clearly identify the role of the nurse and establish the parameters of the

professional relationship. - B

A patient says, "I don't know if I'll make it through this surgery", which response by the nurse may block further communication?

• "You sound scared"
• "You think you will die."
• "Surgery can be frightening"
• "Everything will be alright" - C

A patient, who is to receive nothing by mouth (NPO) in preparation for bronchoscopy says "I'm worried about the test and I can't even have a drink of water." What is the best response by the nurse?

• "Lets talk about your concerns regarding the test".
• "I'll see if the doctor will let you have some ice chips".
• "The doctor will review the results of the test as soon as possible".
• "As soon as the test is over, I'll get you whatever you would like to drink". - A

Which are components of a complete health history? Select all that apply.

• Chief complain
• History of the present illness
• Past medical/surgical history
• Family, personal, and social history
• Review of systems
• Physical exam - A-E, physical exam is not part of the health history

Following amputation of a lower extremity, a patient with prosthesis, should be educated by the nurse to

• Wear the prosthesis daily, but remove immediately when discomfort is

experienced

• Adjust the fit of the prosthesis by wearing a heavier sock to insure a tight fit
• To put the prosthesis on immediately upon rising in the morning and keep it on all

day

• To apply oil or lotion to the stump before applying prosthesis - C

When preparing a client for a blood transfusion, the nurse should consider for which of the following? (Select all that apply)

• Blood typing and cross-matching must be completed prior to a blood transfusion