HESI RN
HESI RN Fundamentals Exam I Questions
Extract:
History and physical
The client is a 69-year-old male with a history of emphysema and hypertension. He presented to the emergency room with shortness of breath and reporting chest pain. He was admitted to the medical floor for cardiac exam and monitoring.
Nurses notes :
1930
The client was alert and oriented when he first came on the unit. Now the client is confused and asking where he is at. His oxygen mask was found on the floor. His lips are blue.
Vital signs
. Heart rate 100 beats/minute
Respiratory rate 29 breaths/minute
. Blood pressure 155/89 mm Hg
Oxygen saturation 75% on room air
Orders:
1845
Admit to medical floor
. Clear liquid diet
12-lead electrocardiogram (ECG)
Apply oxygen 10 L/minute non-rebreather, titrate to keep oxygen saturation greater than 88%
.Send specimens to the laboratory for a blood gas, cardiac enzymes, chemistry, and complete blood count.
Question 1 of 5
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.
Extract:
Question 2 of 5
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
Correct Answer: B
Rationale: Diarrhea risks dehydration, requiring urgent fluid management.
Question 3 of 5
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
Correct Answer: D
Rationale: Simulations promote critical thinking.
Question 4 of 5
The nurse learns that members of the nursing staff are uncomfortable with responding to client family members who are angry. While designing a teaching session to help the staff respond more effectively in these situations, which instructional strategy is best for the nurse to use?
Correct Answer: C
Rationale: Role-playing builds confidence in handling anger.
Question 5 of 5
The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?
Correct Answer: B
Rationale: Sleep apnea increases hypertension risk due to oxygen desaturation.