HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 5
When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?
Correct Answer: C
Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.
Question 2 of 5
The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
Correct Answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management.
Question 3 of 5
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
Correct Answer: D
Rationale: The correct answer is D. The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve). Hearing a whisper (A), identifying an object by touch (B), and shoulder shrugging against resistance (C) are assessments for different cranial nerves.
Question 4 of 5
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
Correct Answer: B
Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period.
Question 5 of 5
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
Correct Answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.
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