HESI RN
HESI RN Fundamentals Exam I 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 has agreed to serve as a client's advocate at the meeting of the hospital ethics committee, which was called to address an ethical dilemma involving the client. To successfully represent the client, what action is essential for the nurse to take?
Correct Answer: A
Rationale: Self-awareness prevents bias in advocacy.
Question 3 of 5
The mother of a child born with Tetralogy of Fallot asks the nurse, 'Why did this happen to my baby? What did I do wrong?' Which response by the nurse is most helpful?
Correct Answer: A
Rationale: Empathy supports emotional expression without judgment.
Question 4 of 5
The nurse plans to encourage a group of young adult clients to engage in problem-solving strategies. Which action is most useful for the nurse to include during the teaching session?
Correct Answer: D
Rationale: Simulations engage active problem-solving.
Question 5 of 5
A small, round raised area appears under the client's skin as the nurse administers an intradermal medication. Which action should the nurse take?
Correct Answer: C
Rationale: Documenting confirms normal intradermal reaction.