HESI RN
HESI Fundamentals Practice Exam
1. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
- A. Document the client’s temperature fluctuations
- B. Assess for flushed, warm skin consistently
- C. Measure temperature at regular intervals
- D. Use different sites for temperature measurement
Correct answer: C
Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.
2. The nurse identifies an electrolyte imbalance, a weight gain of 4.4 lbs in 24 hours, and an elevated central venous pressure for a client with full-thickness burns. Which intervention should the nurse implement?
- A. Administer diuretics
- B. Review urine output
- C. Auscultate for irregular heart rate
- D. Increase oral fluid intake
Correct answer: C
Rationale: An elevated CVP and sudden weight gain indicate fluid overload, which can strain the heart. Auscultating for an irregular heart rate is crucial as electrolyte imbalances and fluid shifts after burns can lead to cardiac complications. Monitoring the heart rate is a priority to detect any cardiac distress early. While reviewing urine output and administering diuretics are important interventions, they should come after ensuring the client's cardiac status is stable. Increasing oral fluid intake may exacerbate the fluid overload, making it an inappropriate intervention in this scenario.
3. A healthcare professional is preparing to administer an enteral feeding via an established NG tube. Which option is not part of the sequence the healthcare professional should follow to initiate the feeding?
- A. Verify tube placement
- B. Check the residual feeding contents
- C. Administer the feeding
- D. Limit protein intake
Correct answer: D
Rationale: The correct sequence for initiating enteral feeding includes verifying tube placement to ensure safety, checking the residual feeding contents to prevent complications, and then administering the feeding. Limiting protein intake is not a step in the sequence for initiating enteral feeding. Protein intake may be adjusted based on the patient's specific nutritional needs, but it is not a part of the immediate sequence for initiating the feeding. Therefore, option D is the correct answer. Options A, B, and C are essential steps to ensure the safe and effective administration of enteral feeding.
4. Pelvic Inflammatory Disease (PID) affects the fallopian tubes resulting in a condition called:
- A. Oophoritis
- B. Endometritis
- C. Salpingectomy
- D. Salpingitis
Correct answer: D
Rationale: Pelvic Inflammatory Disease (PID) is known to affect the fallopian tubes, leading to inflammation, which is termed as salpingitis. Choice A, Oophoritis, refers to inflammation of the ovaries, not the fallopian tubes. Choice B, Endometritis, is inflammation of the endometrium, the inner lining of the uterus, not the fallopian tubes. Choice C, Salpingectomy, is a surgical procedure to remove a fallopian tube and is not a condition caused by PID.
5. The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX, the infant is still not breathing. What action should the nurse take next?
- A. Palpate the femoral pulse and check for regularity.
- B. Deliver cycles of 30 chest compressions and 2 breaths.
- C. Give two breaths that make the chest rise.
- D. Feel the carotid pulse and check for adequate breathing.
Correct answer: C
Rationale: In a scenario where a 6-month-old infant is unresponsive and not breathing after the airway is open, giving two breaths that make the chest rise is the appropriate action. This helps deliver oxygen to the infant's lungs and can help initiate breathing. Chest compressions are not recommended for infants as the first step in resuscitation. Checking pulses like the femoral or carotid pulse is not the priority when an infant is not breathing, as providing oxygen through breaths is essential.