HESI Practice Test for Fundamentals

Correct Answer: A

Rationale: The correct answer is A. Positioning the irrigating solution bag 30 inches below the stoma would cause discomfort and ineffective irrigation as the bag should be positioned at a lower level. Option B is incorrect because a closed system for irrigation is the preferred method for colostomy irrigation. Option C is incorrect as colostomy irrigation is typically done once a day unless otherwise instructed by a healthcare provider. Option D is incorrect as the stoma should be cleaned with mild soap and water to prevent skin irritation and damage.

Correct Answer: A

Rationale: Lorazepam (Ativan) is the most appropriate preoperative medication for a client with severe anxiety. Lorazepam belongs to the benzodiazepine class and is commonly used to manage anxiety before surgical procedures due to its anxiolytic properties. Morphine sulfate and Meperidine (Demerol) are opioid analgesics, not typically indicated for preoperative anxiety. Promethazine (Phenergan) is an antihistamine used for nausea and vomiting, not anxiety management.

Correct Answer: B

Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants. Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (Choice A) may indicate respiratory issues, SCDs (Choice C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (Choice D) are used for DVT prophylaxis but do not alert to hemorrhage.

Correct Answer: A

Rationale: To prevent complications associated with prolonged bed rest, encouraging the client to perform antiembolic exercises every 2 hours is essential. These exercises help promote circulation and prevent blood clots. Instructing the client to cough and deep breathe every 4 hours is beneficial for respiratory function, but it is not as critical as antiembolic exercises. Repositioning the client every 4 hours helps prevent pressure ulcers and maintain skin integrity. Restricting fluid intake is not recommended, as hydration is important for overall health and well-being, especially for clients on bed rest.

Correct Answer: A

Rationale: The nurse's priority is to ensure that the client signs the consent form before the hip surgery. This is crucial as it ensures that the client has provided informed consent for the procedure. Locking valuables, verifying lab values, and administering sedatives are important tasks but ensuring consent takes precedence as it directly impacts the client's right to make decisions about their care.