HESI RN
HESI Fundamentals Practice Exam Questions
Question 1 of 5
A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?
Correct Answer: D
Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.
Question 2 of 5
The healthcare provider is assessing a client with a diagnosis of pneumonia. Which assessment finding is most concerning?
Correct Answer: D
Rationale: A respiratory rate of 28 breaths per minute (D) is most concerning because it indicates respiratory distress and requires immediate intervention. While coarse crackles (A), fever (B), and productive cough (C) are common findings in pneumonia, a high respiratory rate signifies a more severe condition that needs prompt attention to prevent respiratory failure. Monitoring the respiratory rate is crucial in assessing the severity of respiratory distress in pneumonia, as it can rapidly progress to respiratory failure if not managed promptly.
Question 3 of 5
A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Administering regular insulin IV (A) is the initial intervention for a client with diabetic ketoacidosis (DKA) to rapidly reduce blood glucose levels. This is vital in reversing the ketosis and acidosis seen in DKA. Administering IV fluids (B) helps to correct dehydration and electrolyte imbalances. Administering sodium bicarbonate (C) and furosemide (D) may be necessary depending on the client's condition, but insulin administration takes precedence in the management of DKA.
Question 4 of 5
Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?
Correct Answer: C
Rationale: The most accurate method to confirm the proper placement of a nasogastric tube is by examining a chest x-ray obtained after the tubing was inserted. This visual assessment allows healthcare providers to directly visualize the position of the tube in relation to anatomical landmarks, ensuring it is correctly placed in the stomach. Aspirating gastric contents or hearing air pass may provide some information but are not as definitive as a chest x-ray for confirming placement. Checking the remaining length of tubing is not a reliable method for determining proper placement as it does not indicate where the tip of the tube lies within the body.
Question 5 of 5
While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client's foot in a basin of warm water placed on the bed. What action should the nurse take?
Correct Answer: B
Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client's toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.