HESI RN
HESI Fundamentals Practice Test
1. Upon admission, a female client with breast cancer, liver, and spine metastases presents with constant, severe pain despite the continuous use of oxycodone (Percodan) and amitriptyline (Elavil) at home for pain management. What information is most crucial for the nurse to gather during the admission assessment?
- A. Sensory pattern, area, intensity, and nature of the pain.
- B. Identification of trigger points through palpation and manual pressure on painful areas.
- C. Current schedule and total dosages of medications used for breakthrough pain.
- D. Assessment of sympathetic responses indicative of acute pain onset.
Correct answer: A
Rationale: The most critical information for the nurse to obtain during the admission assessment of a client with severe pain due to breast cancer metastasis to the liver and spine is the sensory pattern, area, intensity, and nature of the pain. Understanding these details is essential to tailor appropriate pain management therapy effectively. By assessing the sensory pattern, area, intensity, and nature of pain, the nurse can better determine the underlying cause and choose the most suitable interventions to address the client's pain and improve their quality of life. Trigger points, medication dosages, and sympathetic responses are also important aspects of pain assessment but understanding the sensory aspects of pain is fundamental for providing optimal care in this scenario.
2. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?
- A. Monitor daily urine output volume
- B. Drink plenty of water whenever thirsty
- C. Use salt tablets for sodium content
- D. Review food labels for sodium content
Correct answer: D
Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.
3. What action should the nurse take after applying gloves to irrigate a client's indwelling urinary catheter using an open technique?
- A. Empty the client's urinary drainage bag.
- B. Draw up the irrigating solution into the syringe.
- C. Secure the client's catheter to the drainage tubing.
- D. Use aseptic technique to instill the irrigating solution.
Correct answer: B
Rationale: After applying gloves to irrigate an indwelling urinary catheter using an open technique, the next step for the nurse is to draw up the irrigating solution into the syringe. This step is crucial as it ensures that the solution is ready to be instilled through the catheter to maintain its patency and prevent blockages. Option A is incorrect as emptying the client's urinary drainage bag is not the immediate next step in the irrigation process. Option C is incorrect as securing the client's catheter to the drainage tubing is not necessary at this stage. Option D is incorrect as the question pertains to the action immediately after applying gloves and does not involve instilling the irrigating solution yet.
4. Mr. Landon is scheduled to undergo a tracheostomy. Which nursing action is essential during tracheal suctioning?
- A. Using a water-soluble lubricant.
- B. Administering 100% oxygen before and after suctioning.
- C. Ensuring that the suction catheter is open during insertion.
- D. Assisting the client to assume a semi-Fowler's position during suctioning.
Correct answer: B
Rationale: Administering 100% oxygen before and after suctioning is crucial to prevent hypoxia, which can occur during tracheal suctioning. Hypoxia can lead to serious complications, making the provision of oxygen essential in maintaining adequate oxygenation levels for the patient undergoing tracheal suctioning. Choice A is incorrect because using a water-soluble lubricant is not directly related to the essential nursing action during tracheal suctioning. Choice C is incorrect as ensuring that the suction catheter is open during insertion is a basic requirement and not the essential action for oxygenation. Choice D is incorrect because assisting the client to assume a semi-Fowler's position is beneficial for comfort and airway alignment but is not as crucial as administering oxygen to prevent hypoxia.
5. Which action should the nurse implement when using the confrontation technique during a vision exam?
- A. Use an ophthalmoscope to observe the client's pupil constriction when a strong light is shone on it.
- B. Stand behind the client and direct the client to report when an object enters the peripheral field of vision.
- C. Display a series of four cards with printing of varying sizes to the client and ask which card the client sees most clearly.
- D. Sit facing the client, look directly at the client's face, and move an object inward from the periphery.
Correct answer: D
Rationale: During a vision exam, the confrontation technique is used to assess peripheral vision. By sitting facing the client and moving an object inward from the periphery while looking directly at the client's face, the nurse allows the client to indicate when the object enters the visual field. This method helps in determining the extent of the client's peripheral vision accurately. Choices A, B, and C are incorrect as they do not describe the appropriate method for using the confrontation technique during a vision exam. Choice A involves using an ophthalmoscope to observe pupil constriction, choice B involves testing the peripheral field of vision without the confrontation technique, and choice C describes the Snellen eye chart test for visual acuity, which is not related to the confrontation technique.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99