HESI RN
HESI RN Fundamentals II Questions
Extract:
Question 1 of 5
An older adult client with heart failure has a signed do not resuscitate (DNR) form to put in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP's findings. Which action should the nurse take next?
Correct Answer: B
Rationale: Provider notification confirms DNR status.
Question 2 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 3 of 5
The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer. The UAP pulls the client's auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?
Correct Answer: C
Rationale: Up-and-back auricle pull is correct for adults.
Question 4 of 5
When providing health teaching to older adult clients, which action is most important for the nurse to implement?
Correct Answer: B
Rationale: Plain language enhances comprehension.
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 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:
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.