HESI RN
HESI RN Fundamentals II Questions
Extract:
Question 1 of 5
The nurse is reviewing the admission assessment of a client with chronic pain. What intervention(s) should the nurse include in the client's plan of care?
Correct Answer: B,D,E
Rationale: Pain scale, analgesics, and comfort measures manage chronic pain.
Question 2 of 5
The nurse observes the unlicensed assistive personnel (UAP) securing a client's wrist restraints to the bedside rails. Which action is most important for the nurse to implement?
Correct Answer: C
Rationale: Ensuring restraints are not tight prevents injury.
Question 3 of 5
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement. The client has now developed hyperglycemia which require self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
Correct Answer: D
Rationale: Adherence to insulin regimen manages hyperglycemia.
Question 4 of 5
The palliative care nurse receives a consult for a terminally ill client in the intensive care unit. The client is weak, mouth breathing, and refusing anything to eat or drink. Which intervention should the nurse include in plan of care?
Correct Answer: B
Rationale: Moist membranes enhance comfort in terminal care.
Extract:
History and Physical
The client is a 64-year-old female with a 3-day history of cough and chest pain. She recently began to have difficulty breathing. Cardiac causes of chest pain were ruled out with laboratory tests. The client will be admitted for presumed pneumonia. The client has a history of type 2 diabetes mellitus. She takes insulin glargine 12 units in the morning and 10 units in the evening.
Nurses' Notes
0700
Insulin glargine 12 units given SUBQ.
0900
Azithromycin 1 gm given PO.
1900
Insulin glargine 10 units given SUBQ.
2000
Insulin glargine 10 units given SUBQ.
Imaging Studies
Chest x-ray consolidation in right lower lobe consistent with pneumonia
The primary nurse went on break at 1845. The covering nurse gave insulin glargine and decided to manually document the dose but forgot to enter it into the electronic health record. The primary nurse came back from break and gave a second dose of insulin because of being unaware the covering nurse gave the ordered dose.
Question 5 of 5
What medication error prevention techniques would have helped to avoid this error?
Correct Answer: C,E
Rationale: Immediate documentation and identifiers prevent errors.