HESI RN
HESI RN Fundamentals II Questions
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 1 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.
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.
Extract:
Question 2 of 5
The nurse is teaching a client about a newly prescribed medication. To confirm that the client is learning the critical information, which strategy is most important for the nurse to include during the instruction?
Correct Answer: A
Rationale: Feedback confirms understanding.
Question 3 of 5
The nurse attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?
Correct Answer: B
Rationale: Edema interferes with oximeter accuracy.
Question 4 of 5
A client with chronic fecal incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which intervention should the nurse implement?
Correct Answer: B
Rationale: Post-meal commode use leverages gastrocolic reflex.
Question 5 of 5
The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in plan of care?
Correct Answer: B
Rationale: Moist membranes enhance comfort in terminal care.