HESI RN
HESI RN Fundamentals II Questions
Extract:
Question 1 of 5
The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?
Correct Answer: B
Rationale: Client description reveals pain characteristics.
Question 2 of 5
The nurse is administering an intradermal (ID) injection to a client. Which action should the nurse take?
Correct Answer: D
Rationale: Bevel up ensures proper dermal placement.
Question 3 of 5
Which client assessment should the nurse perform during nasopharyngeal suctioning?
Correct Answer: C
Rationale: Skin/mucous membrane observation monitors distress.
Question 4 of 5
A client is admitted to the rehabilitation unit following a cerebrovascular accident (CVA), which resulted in paralysis of the right arm. When the nurse enters the room, the client is struggling to put on a shirt, and curses at the nurse. Which response is best for the nurse to provide?
Correct Answer: B
Rationale: Empathy addresses client frustration.
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 5 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: 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.