HESI RN
HESI RN Fundamentals II Questions
Extract:
Question 1 of 5
A hospitalized client who has an advance directive and healthcare power of attorney is receiving enteral nutrition through a nasogastric (NG) tube. The client vomits and appears to be choking. Which action should the nurse take?
Correct Answer: D
Rationale: Suctioning clears airway obstruction during choking.
Extract:
History and physical
The client is a 52-year-old female with a history of obesity, type 2 diabetes mellitus, and hypertension. She is in the hospital for treatment of cellulitis of the right leg. The client has a peripherally inserted central catheter (PICC) in her right antecubital vein. She is currently on day 4 of her antibiotic course.
Nurses notes :
The client had a large, loose stool.
Laboratory Results
Laboratory Test Result Reference Range
Blood Glucose 104 mg/dL (5.8 mmol/L) 74 to 106 mg/dL. (4.1 to 5.9 mmol/L)
Orders:
• Vital signs every 4 hours
• Regular diet
• Cefazolin 1 g IV every 8 hours for 5 days
• Metformin 1,000 mg PO every 12 hours
• Point of care blood glucose check every 4 hours
Patient Data
Question 2 of 5
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer:
Rationale: Condition:
Osmotic diarrhea
osmotic diarrhea. This type of diarrhea is often caused by an imbalance in the osmolality of the intestinal contents, which can be due to certain medications or dietary factors. In this case, the client's recent antibiotic therapy and diet might contribute to this condition.
Actions to Take:
Collect stool for culture – This can help determine if there is an infectious or bacterial component contributing to the diarrhea.
Start a high fiber diet – Increasing dietary fiber can help in managing diarrhea by increasing stool bulk and improving consistency.
Parameters to Monitor:
Serum potassium – Osmotic diarrhea can lead to electrolyte imbalances, and monitoring potassium levels helps to detect potential deficiencies.
Serum ketones – This can help to evaluate if the client is in a state of ketosis due to potential malabsorption or significant diarrhea.
Extract:
Question 3 of 5
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
Correct Answer: D
Rationale: Bevel up ensures proper dermal placement.
Question 4 of 5
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours. The vial is labeled, 'Streptomycin 1 gram/2.5 mL.' How many milliliters should the nurse administer? (Enter numerical value only. If rounding is required, round to the nearest tenth.)
Correct Answer: 0.5
Rationale: 200 mg = 0.5 mL from 1 g/2.5 mL vial.
Extract:
History and Physical
The client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intermediate care unit. He lives with his daughter and her family. She reports that he is active and compliant with his medication regime. He walks the dog every morning and has no signs of cognitive decline at home.
Nurses' Notes
0800
Received report. The client is awake and alert. Upon assessment, found a 0.7 in by 1.6 in (2 cm by 4 cm) partial thickness abrasion behind the client's right ear where the strap holding the continuous positive airway pressure (CPAP) mask was positioned.
Orders
• Continuous positive airway pressure (CPAP) 10 cm H2O with supplemental oxygen 55%
• Adjust oxygen as needed to keep oxygen saturation greater than 91%
• Activity as tolerated
• Vital signs every 2 hours
• Diet as tolerated
• Lactated Ringers IV infusion at 90 mL/hr
Question 5 of 5
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
Action to Take
Potential Condition
Parameter to Monitor
Correct Answer: Condition: Stage 1 pressure injury; Actions: Clean the area with sterile saline or wound cleanser and dry, Place a hydrocolloid dressing over the area; Parameters: Temperature, Skin integrity
Rationale: Cleaning and dressing prevent progression; temperature and skin monitor infection.