Questions 9

HESI RN

HESI RN Test Bank

HESI Fundamentals Practice Exam Questions

Question 1 of 5

Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client's plan of care?

Correct Answer: B

Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client's care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.

Question 2 of 5

The census on the unit is 90 percent, and there are no private rooms available. An elderly client with influenza is admitted. Which of the following rooms would it be appropriate to assign this client?

Correct Answer: B

Rationale: When a private room is not an option, the best choice is to assign the elderly client with influenza to a double room with another client diagnosed with the same condition. This is ideal as droplet precautions would likely already be in place for the other client, reducing the risk of spreading the infection to other clients in the unit. Choice A is not appropriate as impetigo does not require the same precautions as influenza. Choice C is not ideal as orthopedic surgery does not involve respiratory precautions. Choice D is incorrect because chickenpox requires airborne precautions, which could pose a risk to the elderly client with influenza.

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

After surgery, a patient has decreased cardiac output. What is a likely observation by the nurse?

Correct Answer: A

Rationale: A decrease in cardiac output can lead to decreased blood flow to the kidneys, resulting in decreased urine output. The kidneys rely on adequate blood supply to filter waste and produce urine. Therefore, a decreased urine output is a common observation when cardiac output is reduced. Choices B, C, and D are incorrect. Increased urine output is not typically associated with decreased cardiac output; flushing of the skin is more related to vasodilation, and hyperventilation is not directly linked to decreased cardiac output.

Question 5 of 5

The client is weak from inactivity due to a 2-week hospitalization. In planning care for the client, which range of motion (ROM) exercises should the nurse include?

Correct Answer: B

Rationale: Active ROM exercises are preferred over passive ROM to restore strength. Performing them on both arms and legs two or three times a day is effective in promoting muscle strength and mobility without the need for external assistance. Choice A is incorrect as passive ROM exercises may not help in restoring strength. Choice C is not recommended as using weights may be too strenuous for a weak client. Choice D is incorrect as passive ROM exercises to the point of resistance and slightly beyond may cause discomfort or injury to the weak client.

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