HESI RN
HESI RN Fundamentals Exam Questions
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 1 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.
Correct Answer:
Rationale: Sterile technique and foam dressing promote healing.
Extract:
Question 2 of 5
The nurse notes that a client has cyanosis of the toes and fingertips. Which vital sign should the nurse obtain first?
Correct Answer: D
Rationale: Cyanosis suggests respiratory issues, needing immediate assessment.
Question 3 of 5
The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?
Correct Answer: D
Rationale: Removing and reinserting prevents discomfort and harm.
Question 4 of 5
Which is the best approach for the nurse to use when interviewing a client about sexuality/reproductive function?
Correct Answer: D
Rationale: Less sensitive questions build rapport.
Question 5 of 5
The nurse is explaining perineal care to the caregiver of a male client. Which information should the nurse include?
Correct Answer: B
Rationale: Non-retractable foreskin should not be forced to prevent discomfort.