HESI RN
HESI RN Fundamentals Exam Questions
Extract:
Question 1 of 5
The healthcare provider gives a verbal prescription for 2 mg of intravenous morphine to be given to a client every 4 hours as needed for severe pain. How should the nurse document the prescription?
Correct Answer: B
Rationale: Full drug name and no trailing zeros ensure clarity.
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 2 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: 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 3 of 5
Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?
Correct Answer: A
Rationale: PCA pump allows self-administered analgesia for immediate pain relief.
Question 4 of 5
When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
Question 5 of 5
The nurse receives a new prescription to administer oxygen at 3 L/minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading of 85% and, after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?
Correct Answer: C
Rationale: Proper cannula placement ensures effective oxygen delivery.