HESI RN
HESI RN Fundamentals Exam Questions
Extract:
Question 1 of 5
An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?
Correct Answer: B
Rationale: Assessing breakdown severity guides treatment planning.
Extract:
History and physical
A 78-year-old female was admitted three days ago with a stage 3 pressure wound at the coccyx. The wound was being cared for at home but has increased in severity from a stage 1 to a stage 3.
Nurses Notes
0800
Head-to-toe assessment complete. Vital signs stable. Pressure injury at the coccyx has anasept in the wound base covered with foam. Dressing clean, dry, and intact.
1200
Client returned from occupational therapy for hip pain. Vital signs stable. Wound dressing clean, dry, and intact.
1500
Client called out on the call light. Reported an incontinent episode. Perineal cleaning and linen
Flowsheet
Vital Signs
0800
• Temperature 98°F. (36.7 °C) orally
• Heart rate 82 beats/minute
• Respiratory rate 14 breaths/minute
. Blood pressure 136/62 mm Hg
1200
• Oxygen saturation 99% on room air
• Patri rating of 1 on 0 to 10 scale, located at соссух
• Temperature 98.4 °F. (36.9 °C) orally
• Heart rate 82 beats/minute
Orders
0830
Wound dressing change every Monday, Wednesday, Friday, and PRN:
Cleanse with normal saline and pat dry Apply anasept gel to wound base. Cover with foam dressing
Question 2 of 5
The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.
| Options | Indicated | Not Indicated |
|---|---|---|
| Gather materials to change soiled items only; | ||
| Thoroughly clean wound using normal saline prior to redressing; | ||
| Place sterile gauze directly on wound bed; | ||
| Apply sterile gloves prior to changing; | ||
| Apply sterile foam dressing over wound bed; |
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.
Extract:
Question 3 of 5
The nurse has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.
Question 4 of 5
The home health nurse is reviewing the personal care needs of an older adult client who lives alone. What client assessment finding(s) indicate(s) the need to assign an unlicensed assistive personnel (UAP) to provide routine foot care and file the client's toenails? Select all that apply.
Correct Answer: A,B,D
Rationale: Tremors, gait issues, and poor vision impair safe foot care.
Question 5 of 5
Which assessment is most important for the nurse to perform prior to the application of a heating pad?
Correct Answer: D
Rationale: Neurosensory impairment risks burns.