HESI RN
HESI Fundamentals Practice Test
1. A client who is in hospice care complains of increasing amounts of pain. The healthcare provider prescribes an analgesic every four hours as needed. Which action should the nurse implement?
- A. Give analgesics on an around-the-clock schedule for pain management.
- B. Administer analgesic medication only when the pain becomes severe.
- C. Provide medication to keep the client comfortable without inducing sedation.
- D. Allow brief medication-free periods to promote comfort during daily activities.
Correct answer: A
Rationale: The most effective pain management strategy in hospice care involves administering analgesics on an around-the-clock schedule (A) to maintain pain control. Waiting until pain is severe before administering medication (B) is not ideal as it may lead to inadequate pain relief. While providing comfort is crucial in hospice care, sedation that prevents the client from interacting and experiencing their remaining time should be minimized. Therefore, keeping the client comfortable without excessive sedation (C) is preferred. Allowing for some periods without medication (D) may be appropriate but should not compromise the client's comfort and pain control.
2. A client with acute pancreatitis is experiencing severe abdominal pain. Which intervention should the nurse implement to help manage the client's pain?
- A. Encourage deep breathing exercises
- B. Place the client in a side-lying position with knees bent
- C. Administer oral analgesics as prescribed
- D. Encourage the client to take small sips of water
Correct answer: B
Rationale: The correct intervention to help manage the client's pain in acute pancreatitis is to place the client in a side-lying position with knees bent. This position can alleviate abdominal pain by reducing pressure on the pancreas and improving comfort. Encouraging deep breathing exercises (Choice A) is beneficial for other conditions but may not directly help alleviate abdominal pain in pancreatitis. Administering oral analgesics (Choice C) may be necessary but is not the initial priority for managing pain in acute pancreatitis. Encouraging the client to take small sips of water (Choice D) is important for hydration but is not directly related to pain management in this context.
3. A healthcare professional is monitoring the respiratory status of a client who has just undergone surgery and is wearing a pulse oximeter. Which of the following coexisting problems is cause for the healthcare professional to suspect that the oxygen saturation readings are not entirely accurate?
- A. Infection
- B. Hypertension
- C. Low blood pressure
- D. Loss of cough reflex
Correct answer: C
Rationale: Low blood pressure (hypotension), shock, and the use of peripheral vasoconstricting medications can lead to inaccurate pulse oximetry readings due to impaired peripheral perfusion. Hypertension and infection are not typically associated with inaccurate pulse oximetry readings, while the loss of cough reflex does not directly affect oxygen saturation readings.
4. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?
- A. Position the client on the right side of the bed in reverse Trendelenburg.
- B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
- C. Reposition the client in the Sims' position.
- D. Raise the side rails on both sides of the bed and elevate the bed to waist level.
Correct answer: C
Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.
5. The client has reinforced instructions for taking cholestyramine (Questran). Which statement indicates a need for further instructions?
- A. I will continue taking vitamin supplements.
- B. This medication will help lower my cholesterol.
- C. This medication should only be taken with water.
- D. A high-fiber diet is important while taking this medication.
Correct answer: C
Rationale: The correct answer is C because cholestyramine should not only be taken with water. Flavored products or fruit juices can improve the taste. Choices A, B, and D are all correct statements. It is important for the client to continue taking vitamin supplements, understand that cholestyramine helps lower cholesterol, and maintain a high-fiber diet while taking this medication to enhance its effectiveness.