HESI RN
HESI Fundamentals Practice Test Questions
Question 1 of 5
After hemodialysis, a client with a history of chronic renal failure has just returned to the unit. What is the most important assessment for the nurse to make?
Correct Answer: D
Rationale: The most crucial assessment for the nurse to make after hemodialysis in a client with chronic renal failure is to check the client's fistula for bruit and thrill (
D). This assessment is essential to ensure the patency of the fistula and adequate blood flow. Auscultating lung sounds (
A), assessing blood pressure (
B), and monitoring weight (
C) are important assessments but are secondary to evaluating the fistula. Checking the fistula is vital as it directly impacts the effectiveness of the client's dialysis treatment and the patency of the vascular access, ensuring successful dialysis sessions.
Question 2 of 5
When caring for an immobile client, what nursing diagnosis has the highest priority?
Correct Answer: B
Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client.
Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.
Question 3 of 5
A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?
Correct Answer: B
Rationale: Kussmaul respirations (
B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DK
A) and are expected in this condition. While oliguria (
A), fruity odor on the breath (
C), and elevated blood glucose level (
D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.
Question 4 of 5
Following a craniotomy, why did the nurse position the client in low Fowler's position?
Correct Answer: B
Rationale: Positioning the client in low Fowler's position after a craniotomy is essential to promote drainage from the operation site. This position helps prevent fluid accumulation, facilitates the removal of excess fluid or blood, and aids in the healing process.
Choice A is incorrect because comfort, while important, is not the primary reason for this specific positioning.
Choice C is incorrect as thoracic expansion is not the main concern following a craniotomy.
Choice D is incorrect as circulatory overload is not typically addressed by positioning in low Fowler's position post-craniotomy.
Question 5 of 5
Which instruction is most important for the nurse to include when teaching a client with limited mobility strategies to prevent venous thrombosis?
Correct Answer: C
Rationale: The most crucial instruction for a client with limited mobility to prevent venous thrombosis is to perform dorsiflexion and plantarflexion of the feet 10 times each hour. These exercises help promote venous return, reducing the risk of thrombosis by preventing blood stasis in the lower extremities. While other measures like turning in bed and staying hydrated are beneficial, promoting venous return through foot exercises is the priority in preventing venous thrombosis in clients with limited mobility. Dorsiflexion and plantarflexion directly target the calf muscle pump, aiding in the circulation of blood back to the heart and preventing clot formation. The other options, such as cough and deep breathing exercises, turning in bed, and hydration, are important for overall health but do not directly address venous stasis and thrombosis prevention in the same way as foot exercises.