HESI Fundamentals Practice Test

Question 1 of 5

What action should the nurse take after applying gloves to irrigate a client's indwelling urinary catheter using an open technique?

A. Empty the client's urinary drainage bag. B. Draw up the irrigating solution into the syringe. C. Secure the client's catheter to the drainage tubing. D. Use aseptic technique to instill the irrigating solution.

Correct Answer: B

Rationale: After applying gloves to irrigate an indwelling urinary catheter using an open technique, the next step for the nurse is to draw up the irrigating solution into the syringe. This step is crucial as it ensures that the solution is ready to be instilled through the catheter to maintain its patency and prevent blockages. Option A is incorrect as emptying the client's urinary drainage bag is not the immediate next step in the irrigation process. Option C is incorrect as securing the client's catheter to the drainage tubing is not necessary at this stage. Option D is incorrect as the question pertains to the action immediately after applying gloves and does not involve instilling the irrigating solution yet.

Question 2 of 5

After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?

A. Is voiding normally. B. Has urinary retention. C. Has developed renal failure. D. Needs an indwelling catheter.

Correct Answer: B

Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying.
Choice A is incorrect because voiding normally would indicate a larger amount of urine output.
Choice C is incorrect as renal failure would typically present with other signs and symptoms.
Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.

Question 3 of 5

The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?

A. At home I take my pills at 8:00 am. B. It costs a lot of money to buy all of these pills. C. I get so tired of taking pills every day. D. This is a new pill I have never taken before.

Correct Answer: D

Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe.

Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect.
Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.

Question 4 of 5

While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

A. Complete the intermittent suction of the nasopharynx. B. Reposition the pulse oximeter clip to obtain a new reading. C. Stop suctioning until the pulse oximeter reading is above 95%. D. Apply an oxygen mask over the client's nose and mouth.

Correct Answer: A

Rationale: A stable oxygen saturation reading of 94% indicates that the nurse can continue with the suctioning procedure. It is within an acceptable range, and there is no immediate need to interrupt the procedure. Continuing with the suctioning will help maintain airway patency and promote adequate oxygenation.
Choice B is incorrect because repositioning the pulse oximeter clip is unnecessary when the reading is stable.
Choice C is incorrect as there is no evidence to support stopping the suctioning procedure solely based on the oxygen saturation reading of 94%.
Choice D is not the best action at this point, as applying an oxygen mask is not indicated when the oxygen saturation is stable and within an acceptable range.

Question 5 of 5

A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?

A. Give analgesics on an around-the-clock schedule for pain management. B. Administer analgesic medication only when the pain becomes severe. C. Provide medication to keep the client comfortable without inducing sedation. D. Allow brief medication-free periods to promote comfort during daily activities.

Correct Answer: A

Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (
A) to maintain pain control. Waiting until pain is severe before administering medication (
B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized.
Therefore, keeping the client comfortable without excessive sedation (
C) is preferred. Allowing for some periods without medication (
D) may be appropriate but should not compromise the client's comfort and pain control.

Nurselytic

HESI RN

HESI RN