HESI RN
HESI RN Fundamentals Exam I Questions
Extract:
Question 1 of 5
When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?
Correct Answer: C
Rationale: Frequent turning prevents pressure ulcers by relieving pressure.
Question 2 of 5
While electronically scanning the client's armband at the bedside prior to administering pain medication, the nurse observes the power flickers and the computer screen goes blank. The computer fails to reboot and the screen remains dark. Which action should the nurse do first?
Correct Answer: A
Rationale: Notifying IT ensures prompt system resolution.
Question 3 of 5
The nurse receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 8-hour shift. Which intervention should the nurse implement first?
Correct Answer: D
Rationale: Checking for kinks ensures catheter functionality.
Question 4 of 5
During the admission assessment to the hospital, a male client reports that he is allergic to latex, penicillin, and bananas. Which intervention should the nurse implement first?
Correct Answer: B
Rationale: Allergy bracelet ensures immediate awareness.
Extract:
History and physical
The client is a 28-year-old male who was admitted to the hospital for seizure medication adjustment. Has been having breakthrough seizures over the past month. Has a neurological disorder causing spasticity and limited ability to speak. Currently, has pain in the right leg of unexplained origin.
Nurses Notes
Administered seizure medication. Moved from chair to bed. Made a sound like moaning. Withdrew right leg from touch. Attempted to place leg in position of comfort but experienced muscle spasm. Facial grimacing
Flowsheet
Heart rate 102 beats/minute
Question 5 of 5
The nurse is planning care for the client.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:
Rationale: Acute pain: The client’s symptoms, such as moaning, facial grimacing, and muscle spasms in the right leg, suggest they are experiencing acute pain. This condition is consistent with the sudden onset of pain and physical reactions.
Request prescription for pain medication: This action addresses the client’s immediate pain needs, helping to alleviate discomfort and improve overall well-being.
Request antispasmodic medication: The muscle spasms observed indicate that an antispasmodic may help reduce the muscle tension and associated pain, providing relief from the spasms.
Response to pain medications: Monitoring the client's response to the prescribed pain medication will help determine the effectiveness of the intervention and whether further adjustments are needed.
Severity of muscle spasms: Assessing the severity of muscle spasms will help evaluate the impact of the antispasmodic treatment and provide insight into the client’s progress in managing the pain.