HESI Fundamentals

HESI RN

1. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?

A. Tell the UAP to use a larger cuff at the next scheduled assessment.
B. Reassess the client's blood pressure using a larger cuff.
C. Have the unit educator review this procedure with the UAPs.
D. Teach the UAP the correct technique for assessing blood pressure.

Correct answer: B

Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.

2. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?

A. Removing the empty food tray from a client with a urinary catheter.
B. Washing and combing the hair of a client with a fractured leg in traction.
C. Administering oral medications to a cooperative client with a wound infection.
D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.

Correct answer: D

Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.

3. The healthcare provider attaches a pulse oximeter to a client's fingers and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

A. BP 142/88 mmHg
B. 2+ edema of fingers and hands
C. Radial pulse volume is +3
D. Capillary refill time is 2 seconds

Correct answer: B

Rationale: Edema in the fingers and hands can impede the proper functioning of the pulse oximeter, leading to a falsely low oxygen saturation reading. Edema alters the transmission of light through the tissues, affecting the accuracy of the measurement. Therefore, the presence of edema in the fingers and hands is the most likely factor contributing to the low oxygen saturation reading of 91%.

4. The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?

A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
B. Retake the blood pressure in the same arm, deflating the cuff slowly.
C. Ask another healthcare provider to recheck the blood pressure to compare results.
D. Obtain another blood pressure cuff and retake the blood pressure.

Correct answer: B

Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.

5. The healthcare professional retrieves hydromorphone 4mg/mL from the Pyxis MedStation, an automated dispensing system, for a client who is receiving hydromorphone 3 mg IM 6 hours PRN for severe pain. How many mL should the healthcare professional administer to the client? (Enter the numerical value only. If rounding is required, round to the nearest tenth)

A. 0.8 mL
B. 0.75 mL
C. 0.7 mL
D. 0.9 mL

Correct answer: A

Rationale: To calculate the mL to administer, divide the ordered dose (3 mg) by the concentration (4 mg/mL). 3 mg Ã· 4 mg/mL = 0.75 mL. Rounding to the nearest tenth, the correct dose to administer is 0.8 mL.