HESI Fundamentals Test Bank

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A nurse is preparing to perform an admission assessment for a client who reports abdominal pain. Which of the following actions should the nurse take?

  • A. Perform deep palpation at the end of the admission assessment
  • B. Auscultate the client's abdomen before palpation
  • C. Begin palpation of the abdomen at the site of pain
  • D. Assess the client's bowel sounds using the bell of the stethoscope
Correct Answer: B

Rationale: Auscultating the abdomen before palpation is the correct action for the nurse to take in this scenario. This approach helps to assess bowel sounds accurately and prevents the alteration of bowel sounds that can occur due to palpation. By auscultating first, the nurse can gather important information about bowel function before proceeding with the palpation. Choice A is incorrect because deep palpation should be avoided initially, especially in a client reporting abdominal pain, as it may cause discomfort or potential harm. Choice C is incorrect as palpation should typically start away from the site of pain to prevent exacerbating discomfort. Choice D is incorrect because assessing bowel sounds with the bell of the stethoscope is not the initial step recommended when a client reports abdominal pain; auscultation should be performed with the diaphragm of the stethoscope first.

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A client with a left leg cast is being taught how to use crutches. Which of the following statements should indicate to the nurse that the client understands the teaching?

  • A. When descending stairs, I will first shift my weight to my right (unaffected) leg.
  • B. I will use crutches to support my weight on my left leg.
  • C. When ascending stairs, I will lead with my left leg.
  • D. I will keep my crutches under my arms for support.
Correct Answer: A

Rationale: The correct answer is A. Shifting weight to the unaffected leg when descending stairs is crucial for maintaining balance and safety. This technique helps prevent falls and distributes weight appropriately. Choices B, C, and D are incorrect because using crutches to support the weight on the injured leg, leading with the injured leg when ascending stairs, and keeping crutches under the arms are all potentially unsafe practices that could lead to further injury or accidents.

A nurse is caring for a group of clients. How should the nurse prevent the spread of infection?

  • A. Place a client with TB in a negative pressure room.
  • B. Use standard precautions only.
  • C. Place a client with TB in a private room.
  • D. Use barrier precautions only.
Correct Answer: A

Rationale: The correct answer is to place a client with TB in a negative pressure room. Tuberculosis (TB) is an airborne infectious disease, and placing the client in a negative pressure room helps prevent the spread of the infection by containing and filtering the air within the room. Standard precautions (Choice B) are important for preventing the spread of infection in general, but specific precautions are needed for airborne diseases like TB. Placing the client in a private room (Choice C) may not provide adequate ventilation and containment of airborne pathogens. Using barrier precautions (Choice D) alone is not sufficient for preventing the airborne transmission of TB.

A client is prescribed a buccal medication. Which of the following client statements indicates that the client understands how to take this medication?

  • A. "I will first dissolve the tablet in water."
  • B. "I will insert the tablet between my cheek and teeth."
  • C. "I will place the tablet under my tongue."
  • D. "I will chew the tablet."
Correct Answer: B

Rationale: The correct way to take buccal medications is to insert the tablet between the cheek and gums where it will dissolve slowly. Option A is incorrect because buccal medications are not meant to be dissolved in water. Option C is incorrect as sublingual medications are placed under the tongue. Option D is incorrect because chewing a buccal tablet is not the correct administration method.

A nurse is preparing to provide tracheostomy care for a client. Which of the following actions should the nurse take first?

  • A. Perform hand hygiene
  • B. Identify the client using two identifiers
  • C. Prepare the sterile field
  • D. Don sterile gloves
Correct Answer: A

Rationale: Performing hand hygiene is essential before any direct patient care procedure to prevent the spread of infection. Proper hand hygiene helps reduce the risk of introducing harmful microorganisms to the client, especially when dealing with a procedure like tracheostomy care. Identifying the client, preparing the sterile field, and donning sterile gloves are all important steps in tracheostomy care, but hand hygiene precedes them to maintain asepsis and ensure patient safety.

After preparing and lubricating the enema set, what is the correct sequence of steps a nurse should follow when administering a large volume enema to a client?

  • A. Administer the enema solution.
  • B. Remove the enema tube from the client's rectum.
  • C. Wrap the end of the enema tube with a disposable tissue.
  • D. Insert the enema tube into the client's rectum.
Correct Answer: B

Rationale: The correct sequence for administering a large volume enema is as follows: 1. Insert the enema tube into the rectum, 2. Administer the enema solution, 3. Clamp the tube, 4. Remove the tube, 5. Wrap the end with tissue. Therefore, the nurse should remove the enema tube from the client's rectum after administering the enema solution. Choices A, C, and D are incorrect because the enema tube should be removed from the rectum after the administration of the solution, not before or during the process.

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