HESI RN Fundamentals Exam 1

Extract:

Question 1 of 5

Which intervention is most important for the nurse to implement before leaving a postoperative client with severe obstructive sleep apnea (OSA) alone?

Correct Answer: C

Rationale: CPAP prevents airway collapse.

Question 2 of 5

The nurse enters a client’s room to perform a physical assessment and finds the client crying. Which response is best for the nurse to provide?

A. Gives the client a hug and says, 'It’s okay to cry when you are sad.' B. While touching the client’s forearm, asks, 'Would you like to talk about it?' C. I’m sorry to disturb you at a difficult time. This can wait until later.' D. This is a bad time. I can see you are upset. I can come back later.'

Correct Answer: B

Rationale: Empathy encourages communication.

Question 3 of 5

After completing daily charting at 1400, the nurse realizes that a 0900 occurrence was not entered. Which is the best way for the nurse to enter computer documentation of the 0900 occurrence?

A. Request removal initiated by the Health Information Manager. B. Make an electronic addendum following the 1400 documentation. C. Create an electronic correction after 1400 notes are officially unlocked. D. Enter the occurrence after the 1400 notes and identify as 'late entry.'

Correct Answer: D

Rationale: Late entries maintain accuracy.

Question 4 of 5

A family requested a visit from a hospice nurse as they think the client appears to be nearing the end of life. The nurse assesses the client. Which of the following signs indicate that the client is near death?

A. Decreased muscle tone, relaxed jaw muscles, sagging mouth. B. Urine output is clear yellow. C. Altered breathing (apnea, labored or irregular breathing, Cheyne-Stokes pattern). D. Congestion/increased pulmonary secretions; noisy respirations (death rattle).

Correct Answer: A,C,D

Rationale: Muscle tone, breathing, and secretions indicate nearing death.

Question 5 of 5

An older adult client with heart failure has a signed do not resuscitate (DNR) form in the medical record. The unlicensed assistive personnel (UAP) reports that the client is not breathing, and the nurse confirms the UAP’s findings. Which action should the nurse take next?

A. Begin cardiopulmonary resuscitation (CPR) and call a code. B. Ask the UAP to complete postmortem care. C. Report the client’s status to the healthcare provider. D. Notify the family of the client’s death.

Correct Answer: C

Rationale: Reporting respects DNR and ensures documentation.

HESI RN Fundamentals Exam 1 | Nurselytic

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HESI RN

HESI RN