HESI RN
Adult Health 1 HESI Questions
Question 1 of 5
At 01:00 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
Correct Answer: A
Rationale: The client has a plan to read until feeling sleepy, indicating an intention to sleep. Therefore, offering a PRN sedative-hypnotic (C) is unnecessary, especially since it is a stronger sleep aid. Option (D) is not needed as the client already has a plan to address his sleeplessness. Assessing the surgical dressing (B) is not relevant to the client's immediate need for sleep. Leaving the room and closing the door (A) is the appropriate action to provide a conducive environment for the client to rest.
Question 2 of 5
A postoperative client has three different PRN analgesics prescribed for different levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What actions should the nurse take first?
Correct Answer: A
Rationale: This is a medication error, and the first step in addressing it is to assess for any side effects of the medication on the patient. Some analgesics can cause respiratory depression, so it is crucial to monitor for vital sign changes or respiratory distress. Once the patient is stable, the next steps would include contacting the provider, documenting the response, and completing a medication error report. Choices B, C, and D are not the immediate priority when dealing with a medication error. While documenting the client's responses and completing a medication error report are important, assessing for side effects and ensuring patient safety come first.
Question 3 of 5
A female client's significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client's estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
Correct Answer: B
Rationale: In this situation, where there is a conflict between the client's significant other and estranged husband, the most appropriate intervention is to request a consultation with the ethics committee for resolution. This ensures that an impartial body can assess the situation, consider the rights and preferences of all parties involved, and provide guidance on how to proceed in a fair and ethical manner. Obtaining a court order (Choice A) may be a legal option but should be considered after exhausting other conflict resolution methods. Involving security (Choice C) may escalate the situation and should only be considered if there is a risk of harm. Discussing boundaries with the client (Choice D) is important but may not immediately address the current conflict between the significant other and the husband.
Question 4 of 5
While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given there is a positive MRSA, which is the most important action for the nurse to take?
Correct Answer: C
Rationale: The most important action for the nurse to take when a client has a positive MRSA and presents with a wound showing signs of infection is to initiate contact precautions. MRSA is highly contagious and placing the patient on contact precautions helps prevent the spread of the bacteria to others in the healthcare setting. (A) Forcing oral fluids will not directly address the MRSA infection. (B) Requesting a nutrition consult is not the priority in this situation. (D) Limiting visitors to immediate family only is not necessary as MRSA precautions are primarily focused on healthcare workers and close contacts who provide direct care.
Question 5 of 5
The nurse is caring for a patient with a massive burn injury and possible hypovolemia. Which assessment data will be of most concern to the nurse?
Correct Answer: A
Rationale: The correct answer is A: "Blood pressure is 90/40 mm Hg." A low blood pressure reading of 90/40 mm Hg indicates that the patient may be developing hypovolemic shock due to intravascular fluid loss from the burn injury. This finding is of utmost concern as it suggests systemic hypoperfusion, requiring immediate intervention to prevent complications. Choices B, C, and D also indicate signs of dehydration and the need to increase fluid intake; however, they are not as urgent as addressing the hypotension and potential shock presented in choice A.