HESI RN
HESI Fundamentals Practice Test
1. A seriously ill female client tells the nurse, 'I am so tired and in so much pain! Please help me to die.' Which is the best response for the nurse to provide?
- A. Administer the prescribed maximum dose of pain medication.
- B. Talk with the client about her feelings related to her own death.
- C. Collaborate with the healthcare provider about initiating antidepressant therapy.
- D. Refer the client to the ethics committee of her local healthcare facility.
Correct answer: B
Rationale: The nurse should prioritize addressing the client's emotional needs by engaging in a conversation to understand the underlying feelings behind her statement. By exploring the client's thoughts about death, the nurse can provide appropriate support and interventions tailored to the client's concerns. Rushing to administer pain medication may not address the emotional distress expressed by the client. Initiating antidepressant therapy is not suitable without assessing the client's feelings further. Referring the client to the ethics committee is premature and does not address the immediate emotional needs of the client. Therefore, empathetic communication and assessment of the client's feelings regarding her situation are crucial for providing holistic care.
2. The RN on the evening shift receives a report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the RN implement the evening before the scheduled ECT?
- A. Hold all bedtime medications.
- B. Keep the client NPO after midnight.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct answer: B
Rationale: Keeping the client NPO after midnight is the appropriate intervention before ECT to prevent complications during the procedure. Withholding food and fluids reduces the risk of aspiration and helps ensure the safety of the client. Option A (Hold all bedtime medications) is incorrect because medications may need to be given as prescribed unless specified otherwise by the healthcare provider. Option C (Implement elopement precautions) is unrelated to preparing a client for ECT and focuses on preventing a client from leaving the treatment area. Option D (Give the client an enema at bedtime) is unnecessary and not a standard pre-ECT preparation, making it an incorrect choice.
3. An elderly client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. Which assessment finding is most concerning for the nurse?
- A. Weight loss of 5 pounds in one week.
- B. Lack of interest in previously enjoyed activities.
- C. Disorganized speech and thought processes.
- D. Severe fatigue and low energy levels.
Correct answer: C
Rationale: In an elderly client with major depressive disorder, disorganized speech and thought processes are the most concerning assessment findings for the nurse. These symptoms can suggest a more severe condition such as psychosis or cognitive impairment, which require immediate attention and intervention. While weight loss, lack of interest in activities, severe fatigue, and low energy levels are common symptoms of major depressive disorder, they do not pose an immediate risk as disorganized speech and thought processes do. Therefore, the nurse should prioritize addressing the disorganized speech and thought processes to ensure the safety and well-being of the client.
4. A nurse plans care for clients with urinary incontinence. Which client is correctly paired with the appropriate intervention?
- A. A 29-year-old client after a difficult vaginal delivery – Habit training
- B. A 58-year-old postmenopausal client who is not taking estrogen therapy – Electrical stimulation
- C. A 64-year-old female with Alzheimer’s-type senile dementia – Bladder training
- D. A 77-year-old female who has difficulty ambulating – Exercise therapy
Correct answer: B
Rationale: The correct pairing is a 58-year-old postmenopausal client who is not taking estrogen therapy with electrical stimulation. Electrical stimulation is used for clients with stress incontinence related to menopause and low estrogen levels. Exercise therapy improves pelvic wall strength and is not specifically for ambulation issues. Habit training is more effective for cognitively impaired clients, like those with Alzheimer's-type senile dementia. Bladder training requires the client to be alert, aware, and able to resist the urge to urinate, which may not be suitable for clients with cognitive impairments.
5. The nurse is caring for a client receiving a blood transfusion who develops urticaria half an hour after the transfusion has begun. What is the first action the nurse should take?
- A. Stop the infusion
- B. Slow the rate of infusion
- C. Take vital signs and observe for further deterioration
- D. Administer Benadryl and continue the infusion
Correct answer: A
Rationale: In the scenario of a client developing urticaria during a blood transfusion, the immediate priority for the nurse is to stop the infusion. This action is crucial to prevent further administration of the allergen causing the reaction. Slowing the rate of infusion (Choice B) may not be sufficient to address the allergic response effectively. While monitoring vital signs (Choice C) is important, stopping the infusion takes precedence to prevent worsening of the reaction. Administering Benadryl (Choice D) should be considered after stopping the infusion, following the healthcare provider's orders, and assessing the client's condition.