HESI RN
HESI RN Fundamentals Exam I Questions
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 1 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.
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 2 of 5
The nurse identifies several nursing problems for a client who is incontinent and immobile after a stroke and is now experiencing diarrhea. The client resides at home and the spouse is the primary caregiver. While planning care, the nurse should determine which problem has the highest priority?
Correct Answer: B
Rationale: Diarrhea risks dehydration, requiring urgent fluid management.
Question 3 of 5
The nurse is performing a routine dressing change for a client with a stage 3 pressure ulcer that is red with significant granulation. The wound has a gauze dressing covering the area. Which action should the nurse implement?
Correct Answer: B
Rationale: Hydrocolloidal dressing promotes healing in granulating wounds.
Question 4 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.
Question 5 of 5
The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.