HESI RN
HESI RN Fundamentals Questions
Extract:
History and Physical
The emergency department (ED) is caring for a 9-month-old male client who was brought to the ED for nasal congestion, cough, fever, and difficulty breathing. The client and his sister both attend daycare daily while their parents are at work. The sister has been acting a bit run down but has not had a fever or oxygen deficit.
Nurse’s Notes
13:30
Upon initial focused assessment, the child reveals subcostal retractions, nasal drainage, skin is hot to the touch, and has a dry cough. Breath sounds reveal diffuse wheezing. Nasal swabs collected and sent to the laboratory. Client’s weight is 12 pounds (5.4 kg).
14:00
Administered acetaminophen PO. Respiratory therapy called for oxygen therapy. 14:45
Respiratory rate and oxygen saturation improved. Temperature is within normal limits. The laboratory called with respiratory panel results. The client is positive for respiratory syncytial virus (RSV).
Laboratory Results
Laboratory
Results
Reference Ranges
Nasal culture Positive for respiratory syncytial virus Negative
Flowsheet Vital Signs
• Temperature: 103°F (39.4°C) recently
• Heart rate: 200 beats/minute
• Respirations: 70 breaths/minute
• Oxygen saturation: 90% on room air
Orders
• Administer 2.5 mL acetaminophen PO every 4 to 6 hours for temperature over 100.4°F (38°C).
• Obtain nasal swab for respiratory nasal culture.
Question 1 of 5
Chart Reviewed: For each statement, click to indicate whether the statement is true or false.
| Options | True | False |
|---|---|---|
| Hand washing only needs to be performed when exiting the client’s room. | ||
| This client requires contact and droplet precautions. | ||
| A gown and gloves should be worn any time there is potential for contact with secretions. | ||
| A mask should always be worn when in the client’s room. | ||
| This client would require a private room if admitted. |
Correct Answer:
Rationale: Hand washing only needs to be performed when exiting the client’s room.
B . This client requires contact and droplet precautions.
C . A gown and gloves should be worn any time there is potential for contact with secretions.
D . A mask should always be worn when in the client’s room.
E . This client would require a private room if admitted.
Solution
Choice A reason: False: Hand washing should be performed not only when exiting the client's room but also before entering the room and after any direct contact with the client or potentially contaminated surfaces within the room.
Choice B reason: True : The client has been diagnosed with Respiratory Syncytial Virus (RSV), which is a highly contagious virus. It can spread through droplets in the air when an infected person coughs or sneezes, or by touching a surface that has the virus on it.
Therefore, contact and droplet precautions are necessary.
Choice C reason: True: Gowns and gloves should be worn whenever there is a potential for contact with secretions, especially when dealing with a patient who has a contagious condition like RSV. This is part of standard precautions to prevent the spread of infection.
Choice D reason: True: A mask should always be worn when in the client's room because RSV can be spread through droplets in the air. This is part of droplet precautions.
Choice E reason: True: This client would require a private room if admitted because RSV is highly contagious. Isolation in a private room is one of the strategies used to prevent the spread of the virus.
Extract:
History and Physical
2/15/2021
The patient is a 36-year-old female who is in the clinic today for insomnia. She reports that she started having trouble sleeping over a year ago after her father’s death. She has no medical problems and has never had surgery. She takes an oral contraceptive and a multivitamin daily. She does not smoke but drinks one to two glasses of wine every evening.
Nurse’s Notes
2/15/2021
Vital Signs:
• Temperature: 97°F (36.1°C) orally
• Heart rate: 59 beats/minute
• Respiratory rate: 16 breaths/minute
• Blood pressure: 116/72 mm Hg
Educated the patient on sleep hygiene techniques, such as avoiding exercise and caffeine right before bed.
3/2/2021
The patient is in the clinic following up after her sleep study, which showed no signs of sleep apnea. The patient continues to have poor sleep even with eliminating caffeine and doing a relaxing activity before bed, such as yoga. The patient will keep a sleep journal to document her sleep for the next 2 weeks.
3/16/2021
The patient completed a 2-week sleep journal. The patient falls asleep 1 to 2 hours after going to bed and wakes up 2 to 3 times per night. She does not have to use the restroom during the night. She experiences daytime drowsiness and headaches nowadays.
Orders
2/15/2021
Sleep study for 1 night.
Question 2 of 5
What other recommendations could the nurse give to help the patient have better sleep? Select all that apply.
Correct Answer: D,E,F
Rationale:
Choice A reason:
Exercising in the evening can actually be counterproductive for some people when it comes to sleep. While regular exercise is beneficial for overall health and can contribute to better sleep, doing it too close to bedtime can stimulate the body, making it harder to relax and fall asleep.
Choice B reason:
Watching television in bed is generally not recommended as part of good sleep hygiene. The light from the screen can interfere with the body's production of melatonin, the hormone that signals it's time to sleep, and engaging content can keep the brain alert rather than allowing it to wind down.
Choice C reason:
Taking an analgesic before bed is not a general recommendation for better sleep unless pain is a specific issue that is preventing sleep. It's important to address the root cause of insomnia rather than masking symptoms with medication.
Choice D reason:
Avoiding alcohol in the evening is a good practice for better sleep. Alcohol can disrupt the sleep cycle and lead to fragmented sleep, even though it may initially seem to help with falling asleep.
Choice E reason:
Going to bed and waking up at the same time every day helps to regulate the body's internal clock, or circadian rhythm, which can improve sleep quality. Consistency is key for this practice to be effective.
Choice F reason:
Avoiding naps, especially in the late afternoon or evening, can help ensure that you are sufficiently tired at bedtime. Napping can interfere with nighttime sleep if done too late in the day or for too long.
Choice G reason:
Eating a heavy meal before bed can lead to discomfort and indigestion, which can make it harder to fall asleep. It's best to have a light snack if needed and avoid large meals close to bedtime.
Extract:
History and Physical
The client is a 56-year-old woman who had an anteroposterior spinal fusion 2 days ago. She tolerated the procedure well and has been progressively increasing her walking distance.
Nurse’s Notes
12:00
Vital Signs:
• Heart rate: 98 beats/minute
• Pain rating: 5 on a 0 to 10 pain scale
Morphine 2.5 mg given IV push (IVP). The client ambulated twice with physical therapy.
13:00
Vital Signs:
• Heart rate: 78 beats/minute
• Pain rating: 3 on a 0 to 10 pain scale
Ibuprofen 800 mg given PO. The client is resting in bed.
14:00
Vital Signs:
• Heart rate: 118 beats/minute
• Pain rating: 8 on a 0 to 10 pain scale
Orders
• Up ad lib
• Regular diet
• Ibuprofen 800 mg PO every 8 hours for pain rated at 2 to 4 on a 0 to 10 pain scale
• Morphine 2.5 mg IV push every 4 hours for pain greater than 4 on a 0 to 10 pain scale
Question 3 of 5
Based on the trending heart rate and pain score, what should the nurse do? Select all that apply.
Correct Answer: A,C,E,F
Rationale:
Choice A reason:
The increase in heart rate from 78 to 118 beats per minute, along with the increase in pain rating from 3 to 8, suggests that the client may be experiencing pain from a source other than the surgical site. It is important to assess for other potential sources of pain to ensure comprehensive pain management.
Choice B reason:
Changing to a behavioral pain scale is not indicated in this scenario. The numerical pain scale is a standard and effective method for assessing pain levels, and there is no indication that the client has difficulty communicating her pain using this scale.
Choice C reason:
Given that the client's pain rating increased to 8, which is above the threshold of 4 on the pain scale, administering a dose of 2.5 mg of morphine as per the orders is appropriate to manage her pain.
Choice D reason:
Referring to social work for drug-seeking behavior is not supported by the information provided. The client's increased pain rating and heart rate suggest a legitimate need for pain management rather than drug-seeking behavior.
Choice E reason:
Bringing an opioid reversal agent to the bedside is not indicated unless there is a concern for opioid overdose, which is not suggested by the information provided.
Choice F reason:
While guided imagery can be a helpful adjunct for pain management, it is not the primary intervention needed at this time given the client's significant increase in pain and heart rate.
Choice G reason:
Consulting with the surgeon about the client's increased pain level is important to rule out any complications from the surgery and to discuss further pain management strategies.
Choice H reason:
Assisting the client to walk around the room may help in pain management and is part of the postoperative care plan to increase walking distance. However, it should be done cautiously considering the client's current pain level.
Extract:
Question 4 of 5
The nurse is assessing a client's pain experience. Which nursing intervention is most effective in determining the severity of a client's pain?
Correct Answer: D
Rationale: Client self-report is the gold standard for pain severity.
Question 5 of 5
Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
Correct Answer: B
Rationale: Log rolling prevents spinal injury by maintaining alignment.