HESI RN
HESI Fundamentals Questions
Question 1 of 5
During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?
Correct Answer: C
Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.
Question 2 of 5
A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
Correct Answer: C
Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.
Question 3 of 5
When making the bed of a client who needs a bed cradle, which action should the nurse include?
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Question 4 of 5
The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
Correct Answer: B
Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.
Question 5 of 5
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
Correct Answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.