HESI RN
HESI Fundamentals
1. A client is admitted with a diagnosis of right-sided heart failure. What assessment finding should the nurse anticipate?
- A. Jugular vein distention.
- B. Crackles in the lungs.
- C. Peripheral edema.
- D. Hepatomegaly.
Correct answer: C
Rationale: In right-sided heart failure, the heart's inability to effectively pump blood to the lungs leads to fluid backup in the systemic circulation, resulting in peripheral edema (swelling in lower extremities). While jugular vein distention (A) and hepatomegaly (D) can also occur in right-sided heart failure, peripheral edema is a hallmark sign due to fluid retention. Crackles in the lungs (B) are more commonly associated with left-sided heart failure, where fluid accumulates in the lungs.
2. A client with Alzheimer's disease is exhibiting signs of agitation and aggression. What is the nurse's priority intervention?
- A. Reassure the client and provide emotional support.
- B. Redirect the client to a quiet activity.
- C. Administer a PRN dose of lorazepam.
- D. Apply soft restraints as needed to prevent harm.
Correct answer: B
Rationale: The correct answer is to redirect the client to a quiet activity. This intervention helps reduce agitation and aggression in clients with Alzheimer's disease by providing a distraction and promoting a calming environment. Reassuring the client and providing emotional support (Choice A) can be beneficial but is not the priority in this situation. Administering a PRN dose of lorazepam (Choice C) should not be the first intervention due to the risk of adverse effects and should only be considered if other non-pharmacological interventions are ineffective. Applying restraints (Choice D) should be avoided unless absolutely necessary for the client's safety as it can lead to further distress and is not the initial priority intervention.
3. A newborn with a yellow abdomen and chest is being assessed. What should be the nurse's initial action?
- A. Assess bilirubin level.
- B. Administer phototherapy.
- C. Encourage feeding to help reduce bilirubin levels.
- D. Perform a bilirubin test every hour.
Correct answer: A
Rationale: The correct action when assessing a newborn with a yellow abdomen and chest is to initially assess the bilirubin level. This helps determine the severity of jaundice in the newborn. Administering phototherapy (choice B) is a treatment intervention that follows the assessment. Encouraging feeding (choice C) can help with bilirubin excretion but is not the initial assessment. Performing a bilirubin test every hour (choice D) may not be necessary initially and could lead to unnecessary interventions.
4. A breastfeeding infant, screened for congenital hypothyroidism, is found to have low levels of thyroxine (T4) and high levels of thyroid-stimulating hormone (TSH). What is the best explanation for this finding?
- A. The thyroxine level is low because the TSH level is high.
- B. High thyroxine levels do not normally occur in breastfeeding infants.
- C. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth.
- D. The TSH is high because of the low production of T4 by the thyroid.
Correct answer: D
Rationale: High TSH and low T4 levels indicate that the thyroid gland is not producing enough hormones, which is a sign of congenital hypothyroidism. In this case, the high TSH is a compensatory response by the body to stimulate the thyroid to produce more T4. Choice A is incorrect because TSH does not directly affect T4 levels; rather, it is the other way around where low T4 levels lead to high TSH levels. Choice B is incorrect because high thyroxine levels are not expected in congenital hypothyroidism. Choice C is incorrect as the thyroid gland should be producing normal levels of thyroxine shortly after birth, making this explanation unlikely in the context of congenital hypothyroidism.
5. What is the primary action of insulin in the body?
- A. To lower blood pressure.
- B. To promote the absorption of glucose into cells.
- C. To increase blood glucose levels.
- D. To decrease blood glucose levels.
Correct answer: B
Rationale: The correct answer is B: To promote the absorption of glucose into cells. Insulin facilitates the uptake of glucose by cells, thereby decreasing blood glucose levels. Choice A is incorrect as insulin does not directly affect blood pressure. Choice C is inaccurate as insulin works to lower, not increase, blood glucose levels. Choice D is incorrect because insulin's primary role is to lower, not increase, blood glucose levels by promoting glucose uptake into cells.