HESI RN
HESI Fundamentals Practice Test
1. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?
- A. Assess for side effects of the medication.
- B. Document the client’s responses.
- C. Complete a medication error report.
- D. Determine if the pain was relieved.
Correct answer: A
Rationale: In the scenario where a nurse administers a medication outside the prescribed parameters, the immediate action should be to assess the client for any potential side effects of the medication. This is crucial to ensure the client's safety and well-being. By promptly assessing for side effects, the nurse can address any adverse reactions promptly and provide necessary interventions. Once the client's safety is ensured, documenting the client's responses, completing a medication error report, and assessing pain relief can follow as part of the broader response to the medication error. Choice B is not the first priority because the immediate concern is the potential harm from the incorrect dose. Choice C is also important but comes after ensuring the client's safety. Choice D focuses on the outcome rather than the immediate need to address any side effects of the medication.
2. A client with type 1 diabetes is admitted with diabetic ketoacidosis (DKA). Which laboratory value requires immediate intervention?
- A. Serum glucose of 300 mg/dl
- B. Serum potassium of 5.5 mEq/L
- C. Serum bicarbonate of 18 mEq/L
- D. Serum sodium of 135 mEq/L
Correct answer: C
Rationale: A serum bicarbonate level of 18 mEq/L requires immediate intervention in a client with diabetic ketoacidosis (DKA). A low serum bicarbonate level indicates metabolic acidosis, which can be life-threatening. This condition needs urgent correction to restore acid-base balance. Serum glucose of 300 mg/dl, serum potassium of 5.5 mEq/L, and serum sodium of 135 mEq/L are abnormal values, but they do not pose an immediate threat to the client's life compared to the metabolic acidosis indicated by the low serum bicarbonate level.
3. A client is learning how to mix regular insulin and NPH insulin in the same syringe. Which action, if performed by the client, indicates the need for further teaching?
- A. Withdraws the NPH insulin first
- B. Withdraws the regular insulin first
- C. Injects air into the NPH insulin vial first
- D. Injects an amount of air equal to the desired dose of insulin into the vial
Correct answer: A
Rationale: When mixing regular insulin with another insulin preparation, it is crucial to withdraw the regular insulin first to prevent contamination. NPH insulin should be drawn after the regular insulin to maintain the integrity of each insulin type. Therefore, if the client withdraws the NPH insulin first, it indicates the need for further teaching. Choice B is correct as withdrawing regular insulin first is the appropriate step. Choice C is incorrect as air should be injected into the vial containing the regular insulin to maintain pressure. Choice D is incorrect as injecting air equal to the desired dose of insulin into the vial is a correct step in preparing the insulin for withdrawal.
4. A client has been receiving hydromorphone every six hours for four days. What assessment should the nurse prioritize?
- A. Increase the dosage of the medication.
- B. Auscultate bowel sounds.
- C. Monitor the client's blood pressure.
- D. Check the client's respiratory rate.
Correct answer: B
Rationale: The correct answer is B. Hydromorphone can cause constipation, a common side effect of opioids. Therefore, it is crucial to auscultate bowel sounds to monitor for signs of decreased gastrointestinal motility. Monitoring blood pressure (choice C) and respiratory rate (choice D) are important but not the priority in this scenario as constipation is a common issue with opioid use. Increasing the dosage of the medication (choice A) is not appropriate without assessing the client's bowel function first.
5. A client with multiple sclerosis is receiving intravenous methylprednisolone. What is the nurse's priority action?
- A. Monitor blood glucose levels every 6 hours.
- B. Monitor for signs of infection.
- C. Encourage increased oral fluid intake.
- D. Check the client's temperature every 4 hours.
Correct answer: B
Rationale: When a client with multiple sclerosis is receiving intravenous methylprednisolone, the nurse's priority action is to monitor for signs of infection. Corticosteroids like methylprednisolone can suppress the immune system, increasing the risk of infection. Monitoring for signs of infection allows for early detection and prompt intervention. Monitoring blood glucose levels may be important in clients receiving corticosteroids for prolonged periods, but it is not the priority in this case. Encouraging increased oral fluid intake is generally beneficial but not the priority over monitoring for infection. Checking the client's temperature is important but not the priority action compared to monitoring for signs of infection.