HESI RN Fundamentals Exam | Nurselytic

Questions 59

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HESI RN Fundamentals Exam Questions

Extract:


Question 1 of 5

A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?

Correct Answer: C

Rationale: Documenting confirms normal intradermal reaction.

Question 2 of 5

While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?

Correct Answer: A

Rationale: Notifying IT ensures prompt system resolution.

Question 3 of 5

The nurse retrieves hydromorphone 4 mg/mL from an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM every 6 hours PRN for severe pain. How many mL should the nurse administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth.)

Correct Answer: 0.8

Rationale: 3 mg ÷ 4 mg/mL = 0.75 mL, rounded to 0.8 mL.

Extract:

History and physical
The client is a 28-year-old male who was admitted to the hospital for seizure medication adjustment. Has been having breakthrough seizures over the past month. Has a neurological disorder causing spasticity and limited ability to speak. Currently, has pain in the right leg of unexplained origin.
Nurses Notes
Administered seizure medication. Moved from chair to bed. Made a sound like moaning. Withdrew right leg from touch. Attempted to place leg in position of comfort but experienced muscle spasm. Facial grimacing
Flowsheet
Heart rate 102 beats/minute


Question 4 of 5

The nurse is planning care for the client.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

Assign a sitter to stay with the client;Have family stay at the bedside;Request antispasmodic medication;Request prescription for pain medication;Use objective symptoms to assess pain

Potential Condition

Chronic pain;Visceral pain;Referred pain;Acute pain

Parameter to Monitor

Vital signs;Decrease in seizures;Response to pain medications;Joint mobility;Severity of muscle spasms

Correct Answer:

Rationale: Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.

Extract:


Question 5 of 5

A female client who is receiving hospice care in her home expresses fear that dying will be painful. Which action should the nurse take first?

Correct Answer: B

Rationale: Discussing fears allows personalized reassurance.

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