HESI RN
HESI Fundamentals Questions
Question 1 of 5
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
Correct Answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.
Question 2 of 5
The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
Correct Answer: B
Rationale: Edema in the fingers and hands can impede the proper functioning of the pulse oximeter, leading to a falsely low oxygen saturation reading. Edema alters the transmission of light through the tissues, affecting the accuracy of the measurement. Therefore, the presence of edema in the fingers and hands is the most likely factor contributing to the low oxygen saturation reading of 91%.
Question 3 of 5
UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?
Correct Answer: D
Rationale: In this scenario, option D is the most critical issue that requires immediate intervention by the nurse. Purulent drainage around the insertion site of the feeding tube indicates a potential infection that needs prompt assessment and treatment to prevent systemic complications. This finding suggests a risk of sepsis, which is a life-threatening condition requiring urgent attention. Option A, the enteral feeding rate of 40 mL/hr, is within a normal range and does not pose an immediate threat to the client's safety. Option B, a full urine meter, indicates the need to empty the drainage bag but does not present an urgent concern for the client's well-being. Option C, a dependent loop in the urinary drainage tubing, can impede urine flow but is not as critical as a potential infection indicated by purulent drainage. By prioritizing the assessment and management of the purulent drainage, the nurse can address the most pressing issue affecting the client's health and prevent further complications. Educationally, this question highlights the importance of prioritizing nursing interventions based on the urgency of the client's condition. It emphasizes the significance of recognizing signs of infection and taking immediate action to prevent serious consequences for the client. This rationale underscores the critical thinking skills required in nursing practice to prioritize care effectively and ensure patient safety and well-being.
Question 4 of 5
Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?
Correct Answer: B
Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client's discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.
Question 5 of 5
The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?
Correct Answer: D
Rationale: In this scenario, the correct answer is D) Rely on cultural norms as the basis for providing healthcare for this client. This is the most appropriate action because it acknowledges the importance of cultural competence in nursing care. Understanding and respecting the cultural background of a patient is essential in providing effective and holistic healthcare. Option A is incorrect because just providing an interpreter does not address the broader cultural considerations that should be taken into account. While language translation is important, it is not sufficient to ensure culturally sensitive care. Option B is incorrect as commending the client for patience does not directly address the cultural aspects that may impact the patient's care and experience during the admission process. Option C is incorrect as assuming the need for a chaplain based solely on the patient's cultural background is not appropriate. It is important to respect the client's beliefs and preferences regarding spiritual care rather than making assumptions based on ethnicity. In an educational context, it is crucial for nursing students to understand the significance of cultural competence in nursing practice. Providing culturally sensitive care leads to better patient outcomes, increased trust between the healthcare provider and patient, and overall improved quality of care. Nurses should be equipped with the knowledge and skills to effectively assess and address the cultural needs of diverse patient populations to deliver patient-centered care.