HESI RN
HESI RN Fundamentals Exam Questions
Extract:
Question 1 of 5
In-home hospice care is arranged for a client with stage 4 lung cancer. While the palliative care nurse is arranging for discharge, the client verbalizes concerns about pain. Which action should the nurse implement?
Correct Answer: D
Rationale: Scheduled analgesics ensure consistent pain relief.
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.
Extract:
History and physical
The client is a 44-year-old male with cerebral palsy who is non-verbal and has severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses notes
1000
Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.
Question 3 of 5
Review H and P and nurse's note.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: Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.
Extract:
Question 4 of 5
Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?
Correct Answer: C
Rationale: Commode prevents enema expulsion accidents.
Question 5 of 5
The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? (Select all that apply)
Correct Answer: C,D,E
Rationale: Orienting, alarming, and escorting ensure safety.