HESI Fundamentals - Set 3 - Part 1

Correct Answer: Side-lying with suction available

Side-lying position lets fluid drain from the mouth by gravity rather than entering the airway. Suction within reach allows the nurse to clear pooled secretions immediately if any begin to accumulate during care. Option b is incorrect because Supine flat with the mouth open invites aspiration because gravity pulls fluid toward the trachea. Without an active gag, the patient cannot protect the airway from any liquid that pools in the back of the throat. Option c is incorrect because Trendelenburg with the head down forces fluid back toward the airway. The position is unsafe for oral care in any patient who cannot protect the airway from secretions running backward toward the throat. Option d is incorrect because Upright at ninety degrees can be unsafe if the patient slumps forward and aspirates. Side-lying is preferred for the unconscious patient because gravity drains fluid out rather than down the airway.

Correct Answer: Wipe front to back with one stroke

Wiping front to back moves bacteria away from the urethra and toward the anal area. Using a fresh portion of cloth for each stroke prevents reintroducing pathogens to the cleaned area during care. Option a is incorrect because Wiping back to front pulls fecal flora toward the urethra and increases the risk of infection. The direction violates basic perineal hygiene principles and is one of the most common errors taught against in basic care training. Option b is incorrect because Circular wiping spreads bacteria across the entire perineal area without a clear cleaning direction. The technique increases contamination of the urethra by bringing fecal organisms into contact with the meatus during the round. Option d is incorrect because Reusing the same cloth side repeatedly drags bacteria back across already-cleaned areas. The nurse must use a fresh cloth or fresh portion for each stroke during perineal care to maintain safety.

Correct Answer: Brush over towel-lined sink with water

Brushing dentures over a towel-lined sink filled with water cushions any drop and prevents breakage. The nurse uses cool water and a soft brush, then stores dentures in solution overnight to keep them clean. Option a is incorrect because Hard countertops without padding risk shattering dentures if they slip from the nurse's hands. Dentures are expensive and difficult to replace quickly, so the nurse always lines the work surface with a soft towel. Option b is incorrect because Boiling water can warp denture material and ruin the fit. The nurse uses cool water for cleaning and a denture cleanser solution for soaking, never boiling temperatures that damage the acrylic structure. Option c is incorrect because Storing dentures dry overnight allows the material to warp and crack. The nurse stores dentures in clean water or a denture cleanser solution to maintain shape and reduce bacterial growth.

Correct Answer: Modified bed bath with assistance

A modified bed bath with assistance conserves energy while keeping skin clean. The nurse can let the patient wash easily-reachable areas and complete the rest, supporting both autonomy and recovery without excessive exertion. Option a is incorrect because A full tub bath demands more strength and balance than the patient can safely provide. The transfer in and out of the tub increases fall and exhaustion risk, especially for someone with severe fatigue. Option c is incorrect because A standing shower for ten minutes is too long for someone with severe fatigue. Even with a shower chair, the trip to the bathroom and the duration may exceed the patient's tolerance and energy reserve. Option d is incorrect because A cold sponge bath while lying flat would be uncomfortable and chilling, and the position adds aspiration risk. The temperature also offers no clinical benefit and could cause shivering and increased oxygen demand.

Correct Answer: Inspect feet daily and wear closed shoes

Daily foot inspection catches small injuries early before they become ulcers. Closed shoes protect against punctures and burns, especially when neuropathy reduces sensation and the patient may not feel a stepped-on sharp object. Option a is incorrect because Soaking feet in hot water risks burns when sensation is impaired by neuropathy. The patient may not feel water that is too hot, and prolonged moisture also weakens skin and promotes maceration between toes. Option b is incorrect because Cutting toenails in a deep curve at the corners increases the risk of ingrown toenails. The nurse teaches straight-across trimming with smooth edges to prevent injury and infection of the surrounding skin. Option d is incorrect because Walking barefoot at home invites punctures from small objects on the floor. With diminished sensation, the patient may step on something sharp without feeling it and develop a wound that festers unnoticed.

Correct Answer: Hold cane in left hand opposite weak

The cane is held in the hand opposite the weak side. With right-sided weakness, the cane goes in the left hand, advancing with the weak right leg to redistribute weight and improve stability. Option b is incorrect because Holding the cane on the same side as the weakness narrows the base of support. The body still leans toward the weak side, and the cane cannot widen the base or share the load effectively. Option c is incorrect because Switching hands every few steps disrupts the gait pattern and adds confusion. The cane should remain on the strong side throughout walking so the patient can develop a steady, predictable pattern of movement. Option d is incorrect because Holding the cane behind the back removes any support function it provides. The cane works only when planted at the side and slightly forward to bear weight as the weak leg moves through.

Correct Answer: Use transfer device with two staff

Using a transfer device with two staff members protects the nurse from back injury and the patient from falls. Mechanical lifts and slide boards reduce manual lifting load and follow safe handling guidelines used today. Option a is incorrect because Bending at the waist places strain on the lower back and risks injury. Safe body mechanics call for bending at the knees, keeping the back straight, and using leg muscles for the lifting force. Option b is incorrect because Twisting while lifting is one of the most common causes of back injury for nurses. The nurse should pivot the feet rather than twist the spine when the load needs to be moved sideways. Option c is incorrect because Lifting alone to save staff time creates injury risk for both nurse and patient. Two-person transfers and lift devices are standard for heavy patients, and skipping help is unsafe regardless of time pressure.

Correct Answer: Venous thromboembolism risk increase

Prolonged immobility raises the risk of venous thromboembolism through stasis in deep veins. The nurse uses sequential compression devices, encourages leg exercises, and ensures hydration to reduce clot formation during the recovery period. Option a is incorrect because Increased appetite and weight gain are not typical complications of prolonged immobility. Most immobile patients lose appetite and muscle mass, not gain weight, so the option misrepresents the actual physiologic effects observed. Option b is incorrect because Circulation in deep veins worsens, not improves, during immobility. Stasis sets up the conditions for clot formation, so the option describes the opposite of what really happens with prolonged bed rest. Option d is incorrect because Wound healing slows during immobility because of decreased perfusion and muscle wasting. Movement actually supports healing, while inactivity weakens tissue and prolongs recovery time after surgery and other procedures.

Correct Answer: Standard walker to cane to no device

The standard progression goes from walker to cane to no device as strength and balance improve. The walker offers maximum stability, the cane partial support, and independent walking is the goal for recovery. Option b is incorrect because Skipping from walker straight to no device removes the intermediate support of a cane. The patient can become unsteady or experience renewed pain without the cane bridging the gap between walker and independent walking. Option c is incorrect because Going to a cane before a walker reverses the progression and is less safe early after surgery. Walkers offer a wider base of support, which is needed first when balance and confidence are still recovering. Option d is incorrect because Crutches require upper body strength and coordination beyond what most post-hip patients have. Walkers are the standard early device after hip surgery, and crutches are not a typical step in this recovery pathway.

Correct Answer: Use gait belt, stand on weak side

A gait belt with the nurse on the patient's weaker side allows controlled support during transfer. The belt provides a secure handhold and lets the nurse guide the patient down safely if balance falters. Option a is incorrect because Pulling the patient by both arms can dislocate shoulders and does not provide a controlled descent. The technique also leaves the nurse without secure support if the patient becomes unsteady mid-transfer suddenly. Option c is incorrect because Walking fast during the transfer increases fall risk because the patient cannot keep pace. The nurse moves slowly, gives clear instructions, and pauses if the patient appears unsteady or shows signs of weakness. Option d is incorrect because Skipping the gait belt removes a key safety tool from the transfer. The few seconds saved are not worth the increased risk of fall and injury during the move from bed to chair.

Correct Answer: Sit upright at ninety degrees during meal

Sitting upright at ninety degrees with chin slightly tucked supports safe swallowing. Gravity directs food past the airway and into the esophagus, while the upright posture keeps the trachea protected during the meal. Option a is incorrect because Reclining to thirty degrees does not provide enough support for active swallowing. The patient needs to be fully upright during meals to use the swallow mechanics correctly and minimize aspiration risk every time. Option b is incorrect because Tilting the head back during swallowing opens the airway to food rather than directing it to the esophagus. Chin tuck or neutral head position is preferred to protect the airway during each bite. Option c is incorrect because Lying flat with the face to the side raises aspiration risk because gravity no longer directs food away from the airway. The patient must be upright for safe oral intake to be possible at all.

Correct Answer: Check pH of aspirate and external length

Checking pH of aspirate and confirming external tube length match the documented placement provide the best bedside verification. A radiographic study confirms initial placement, while these bedside checks are repeated before each feeding. Option a is incorrect because Auscultation alone is not reliable because air can be heard from a misplaced tube in the lungs. Current evidence-based practice has moved away from auscultation as a sole verification method for tube placement. Option b is incorrect because The air bolus method has been shown to be inaccurate for distinguishing gastric from pulmonary placement. Sounds from a tube in the lung can mimic gastric sounds, making the technique unsafe to rely on alone. Option d is incorrect because Visual inspection of the nostril does not confirm where the distal tip of the tube actually sits. The tube can move internally without external displacement, so this method alone provides no real safety assurance.

Correct Answer: Low-protein, low-potassium, low-phosphorus

Patients with chronic kidney disease typically need diets lower in protein, potassium, and phosphorus. The damaged kidneys cannot handle normal loads, and dietary control limits the buildup of waste and electrolyte disturbances. Option b is incorrect because Heart failure rather than kidney disease typically calls for sodium and fluid restriction. The mismatch with kidney disease shows that the option misidentifies the organ system pathway and the relevant dietary changes here. Option c is incorrect because Unrestricted protein and high potassium would worsen uremia and risk hyperkalemia in kidney disease. The diet must restrict both substances to protect the kidneys and maintain safe electrolyte balance for the patient. Option d is incorrect because High-phosphorus dairy worsens phosphate retention in chronic kidney disease and contributes to bone disease. The diet must limit phosphorus, including dairy, processed foods, and dark sodas to reduce the burden.

Correct Answer: Verify with second nurse and start slowly

Independent double-check of TPN content and a slow controlled start reduce errors and refeeding complications. The nurse monitors glucose, electrolytes, and fluid balance closely during the early hours of the infusion. Option a is incorrect because Starting at maximum rate to catch up calories risks refeeding syndrome and rapid glucose shifts. The infusion is started slowly and titrated up, allowing the body to adjust safely to the high-calorie load over time. Option b is incorrect because Standard TPN has a high osmolarity that damages peripheral veins. Central venous access is required, and using a peripheral line for full TPN causes phlebitis and tissue injury at the infusion site. Option c is incorrect because Glucose monitoring is essential during TPN because the high dextrose load can cause hyperglycemia. Skipping checks misses dangerous trends, and many patients need adjustments to insulin or formula based on real-time results.

Correct Answer: Cluster nursing care to allow rest periods

Clustering nursing care into fewer interruptions allows longer stretches of uninterrupted sleep. The nurse coordinates assessments, medications, and personal care so the patient experiences consolidated rest periods through the night. Option a is incorrect because Bright lights overnight disrupt circadian rhythm and prevent restorative sleep. Dim lighting and limited use of overhead lights during nighttime nursing care are part of standard sleep hygiene measures on the unit. Option b is incorrect because Loud roommate activity may be common but can often be reduced with coordinated quiet times. Treating it as unavoidable misses the nursing role in advocating for the patient's environment and rest. Option d is incorrect because Frequent unannounced checks fragment sleep and prevent any deep stages from completing. The nurse should consolidate care and communicate timing whenever possible so the patient can anticipate and recover between visits.

Correct Answer: Encourage fluids and ambulation as tolerated

Encouraging fluids and ambulation supports natural bowel function. Hydration softens stool and movement stimulates peristalsis, both of which help relieve constipation without invasive procedures or unprescribed medications during the patient's stay. Option a is incorrect because Restricting fluids worsens constipation by hardening stool further. Adequate hydration is foundational to bowel health, and reducing intake without specific reason directly contradicts standard nursing care for the constipated patient. Option c is incorrect because Manual disimpaction requires a provider order and assessment for impaction first. Reaching to break stool without confirmation and approval is outside standard nursing practice and could injure the rectum or trigger vagal response. Option d is incorrect because Waiting several more days without intervention allows constipation to worsen and potentially become impaction. The nurse should act on the cue now with non-invasive measures rather than

Correct Answer: Stoma appears dark purple or black

A dark purple or black stoma indicates compromised blood supply and possible tissue necrosis. The nurse notifies the provider immediately, since prompt evaluation may prevent loss of the stoma and additional surgical revision. Option b is incorrect because Bright pink and moist appearance describes a healthy stoma with adequate blood flow. The finding is reassuring, not alarming, and reflects the normal expectation during the early postoperative recovery period for a new ostomy. Option c is incorrect because Shiny and slightly raised is normal for a new stoma. The mucosal surface naturally appears glossy because it does not have keratinized skin, and the appearance does not indicate any complication of the surgery. Option d is incorrect because A red color with mild bleeding can be normal in the first days after surgery, since the mucosa is fragile and easily traumatized. Significant bleeding raises concern, but slight oozing during care is expected.

Correct Answer: Keep bag below bladder, ensure closed system

Keeping the drainage bag below the level of the bladder uses gravity to prevent backflow into the bladder. Maintaining the closed system reduces the introduction of bacteria along the catheter pathway during care. Option a is incorrect because Disconnecting the closed system breaks sterile barriers and increases infection risk. The system should remain closed except for emptying through the spout, and routine disconnection has no benefit during routine care. Option b is incorrect because Hanging the bag above bladder level allows urine to flow back toward the bladder. Reflux of urine carries pathogens upward and increases the chance of catheter-associated urinary tract infection during the stay. Option c is incorrect because Routine tubing changes every twelve hours are unnecessary and disrupt the closed system. Tubing is changed only when contamination, leak, or specific clinical concern requires intervention rather than on a fixed short interval.

Correct Answer: Clean front to back, collect midstream

Cleaning front to back with the provided wipe and collecting the middle portion of the urine stream gives a clean-catch specimen. Initial flow flushes the urethral opening, then midstream urine enters the sterile container. Option a is incorrect because Collecting the first portion of the stream captures contaminating organisms from the urethral opening. The midstream collection bypasses these organisms and provides a more accurate result for culture or urinalysis testing. Option b is incorrect because Skipping perineal cleaning before collection invalidates the clean-catch part of the specimen. The clean technique exists specifically to reduce surface contamination, and omitting it produces unreliable results for the laboratory analysis. Option d is incorrect because Using an unsterile cup contaminates the specimen with environmental organisms. The clean-catch protocol uses a sterile container precisely so that any bacteria found come from the urinary tract rather than the cup.

Correct Answer: Bladder scan and then offer voiding measures

A bedside bladder scan quantifies retention noninvasively and informs the next step. The nurse can also offer non-invasive measures like running water, perineal warmth, and a private bathroom before any catheter is considered. Option b is incorrect because Inserting an indwelling catheter without first quantifying retention or trying non-invasive measures is premature. Catheterization carries infection risk and should be reserved for confirmed retention that does not resolve with simpler interventions first. Option c is incorrect because Documenting and continuing rounds ignores a patient with bladder distention and discomfort. The finding requires action, not passive monitoring, since prolonged retention can cause bladder injury and worsening pain over the next hours. Option d is incorrect because Encouraging three large glasses of fluid worsens bladder distention without addressing the retention. Fluid intake will not help when the patient cannot empty the bladder; the priority is to