HESI RN
HESI RN Fundamentals Exam I Questions
Extract:
Question 1 of 5
Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?
Correct Answer: A
Rationale: Log rolling maintains spinal alignment for safety.
Extract:
History and physical
The client is a 44-year-old male with cerebral palsy who is non-verbal and has severe intellectual disability. He requires total care at home, which is provided by his two sisters, a home health nurse, and an unlicensed home health aide. The client is currently in the hospital for a lower respiratory infection.
Nurses notes
1000
Noted the client's clothes and sheets are wet. The client voided approximately 75 mL of urine. The client's sister says that he usually wears adult diapers at home as he is unable to communicate when he needs to void.
Question 2 of 5
Review H and P and nurse's note.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: Overflow urinary incontinence: The client's condition, which includes wet clothes and sheets with a small volume of urine voided, suggests overflow urinary incontinence, where the bladder is not completely emptied and leaks small amounts of urine.
Place an incontinence containment product under the client: This action helps manage urinary incontinence by absorbing leaked urine and keeping the client dry, thereby preventing skin breakdown and discomfort.
Provide skin care: Regular skin care is essential to prevent skin irritation, breakdown, and potential infections, especially when the client is incontinent.
Intake and output: Monitoring intake and output is crucial in assessing the client's fluid balance and urinary function, ensuring that the incontinence is managed effectively.
Skin integrity: Monitoring skin integrity is necessary to identify any signs of pressure ulcers or skin breakdown, which can result from prolonged exposure to moisture due to incontinence.
Extract:
Question 3 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.
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 4 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.
Extract:
Question 5 of 5
The nurse knows that skin turgor changes with age. Which intervention is most helpful in dealing with normal aging changes of the skin?
Correct Answer: A
Rationale: Lotion combats dryness in aging skin.