HESI RN
HESI RN Fundamentals Exam Questions
Extract:
Question 1 of 5
The nurse is preparing a client placed on droplet precautions for transport from the client's room to another department. The client wears eyeglasses and refuses to remove them while being transported. Which action should the nurse take?
Correct Answer: D
Rationale: Surgical mask ensures droplet precaution compliance.
Question 2 of 5
A bedfast female client awakens during the night, reporting to the nurse that she is 'uncomfortable.' What action should the nurse implement first?
Correct Answer: D
Rationale: Repositioning often relieves discomfort.
Question 3 of 5
A client, who speaks very little English, is being seen in the emergency department following an automobile accident. The client's sibling offers to act as an interpreter and asks about the laboratory results. Which response is best for the nurse to provide?
Correct Answer: A
Rationale: Approved interpreter ensures confidentiality.
Question 4 of 5
The nurse observes that a client on a clear liquid diet has a cup of coffee on the breakfast tray. Which action should the nurse implement?
Correct Answer: C
Rationale: Black coffee is allowed without additives.
Extract:
History and physical
A 78-year-old female was admitted three days ago with a stage 3 pressure wound at the coccyx. The wound was being cared for at home but has increased in severity from a stage 1 to a stage 3.
Nurses Notes
0800
Head-to-toe assessment complete. Vital signs stable. Pressure injury at the coccyx has anasept in the wound base covered with foam. Dressing clean, dry, and intact.
1200
Client returned from occupational therapy for hip pain. Vital signs stable. Wound dressing clean, dry, and intact.
1500
Client called out on the call light. Reported an incontinent episode. Perineal cleaning and linen
Flowsheet
Vital Signs
0800
• Temperature 98°F. (36.7 °C) orally
• Heart rate 82 beats/minute
• Respiratory rate 14 breaths/minute
. Blood pressure 136/62 mm Hg
1200
• Oxygen saturation 99% on room air
• Patri rating of 1 on 0 to 10 scale, located at соссух
• Temperature 98.4 °F. (36.9 °C) orally
• Heart rate 82 beats/minute
Orders
0830
Wound dressing change every Monday, Wednesday, Friday, and PRN:
Cleanse with normal saline and pat dry Apply anasept gel to wound base. Cover with foam dressing
Question 5 of 5
The wound care nurse is preparing to change the client's dressing. For each technique item, click to indicate whether the technique is indicated or not indicated. Each row must have one option selected.
| Options | Indicated | Not Indicated |
|---|---|---|
| Gather materials to change soiled items only; | ||
| Thoroughly clean wound using normal saline prior to redressing; | ||
| Place sterile gauze directly on wound bed; | ||
| Apply sterile gloves prior to changing; | ||
| Apply sterile foam dressing over wound bed; |
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.