HESI RN
HESI Fundamentals Practice Test Questions
Question 1 of 5
An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?
Correct Answer: D
Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.
Question 2 of 5
When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?
Correct Answer: A
Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension.
Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.
Question 3 of 5
During a 30-second interval, the nurse counts six respirations, and the client coughs three times. In repeating the count for a second 30-second interval, the nurse counts eight respirations. What respiratory rate should the nurse document?
Correct Answer: B
Rationale: The nurse should document a respiratory rate of 16. The second count of eight respirations in a 30-second interval is the most accurate as it was not interrupted by the client coughing.
Therefore, this rate reflects the client's typical respiratory pattern and should be documented.
Choices A, C, and D are incorrect as they do not consider the interruption caused by the client coughing during the first count, which could have affected the accuracy of the result. The second count of eight respirations provides a more reliable indication of the client's respiratory rate.
Question 4 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 5 of 5
After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?
Correct Answer: B
Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.