HESI RN
HESI RN Fundamentals Exam Questions
Extract:
History and physical
The client is a 69-year-old male with a history of emphysema and hypertension. He presented to the emergency room with shortness of breath and reporting chest pain. He was admitted to the medical floor for cardiac exam and monitoring.
Nurses notes :
1930
The client was alert and oriented when he first came on the unit. Now the client is confused and asking where he is at. His oxygen mask was found on the floor. His lips are blue.
Vital signs
. Heart rate 100 beats/minute
Respiratory rate 29 breaths/minute
. Blood pressure 155/89 mm Hg
Oxygen saturation 75% on room air
Orders:
1845
Admit to medical floor
. Clear liquid diet
12-lead electrocardiogram (ECG)
Apply oxygen 10 L/minute non-rebreather, titrate to keep oxygen saturation greater than 88%
.Send specimens to the laboratory for a blood gas, cardiac enzymes, chemistry, and complete blood count.
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:
Rationale: Hypoxia: The client's symptoms of confusion, blue lips (cyanosis), and a low oxygen saturation of 75% on room air indicate severe hypoxia, which requires immediate intervention to restore adequate oxygenation.
Replace the non-rebreather mask: This action ensures that the client receives the prescribed oxygen therapy at the correct flow rate, which is critical for increasing oxygen levels in the blood.
Increase the flow of oxygen to 12 L: Adjusting the oxygen flow rate to the prescribed level is necessary to effectively increase the client's oxygen saturation and relieve hypoxia.
Oxygen saturation: Monitoring oxygen saturation is essential to assess the effectiveness of the oxygen therapy and ensure that the client's oxygen levels are being maintained above 88%, as per the orders.
Level of consciousness: Monitoring the client’s level of consciousness helps evaluate the impact of hypoxia on the brain and determines whether the interventions are improving the client's neurological status.
Extract:
Question 2 of 5
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
Correct Answer: D
Rationale: Cyanosis suggests respiratory issues, needing immediate assessment.
Question 3 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.
Question 4 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.
Question 5 of 5
The nurse observes a colleague sharing computer credentials with a colleague who is struggling with access to the electronic health record (EHR). Which action should the nurse take?
Correct Answer: C
Rationale: Reporting to the charge nurse ensures prompt action.