HESI RN
HESI Fundamentals Practice Exam
1. When assisting an older client who can stand but not ambulate from the bed to a chair, what is the best action for the nurse to implement?
- A. Use a mechanical lift to transfer the client from the bed to a chair.
- B. Place a roller board under the client who is sitting on the side of the bed and slide the client to the chair.
- C. Lift the client out of bed to the chair with another staff member using a coordinated effort on the count of three.
- D. Place a transfer belt around the client, assist the client to stand, and pivot to a chair that is placed at a right angle to the bed.
Correct answer: D
Rationale: The best action for the nurse when assisting an older client who can stand but not ambulate from the bed to a chair is to use a transfer belt. Placing a transfer belt around the client, assisting the client to stand, and pivoting to a chair that is placed at a right angle to the bed allows for a safe and controlled transfer. This method promotes patient independence while ensuring safety during the transfer process. Choices A, B, and C are incorrect because using a mechanical lift may not be necessary for a client who can stand, using a roller board may not provide enough stability, and lifting the client with the help of another staff member may not be the safest option for the client's independence and safety.
2. A 4-year-old child with a history of asthma is brought to the clinic with a complaint of cough and wheezing. The nurse notes that the child has been using a rescue inhaler more frequently over the past week. What should the nurse do next?
- A. Review the child’s asthma action plan
- B. Administer a dose of the rescue inhaler
- C. Instruct the parents to increase the dose of the controller medication
- D. Schedule a follow-up appointment in one week
Correct answer: A
Rationale: In this scenario, the best course of action for the nurse is to review the child's asthma action plan. By doing so, the nurse can assess the current asthma management, ensure that the child is using the rescue inhaler correctly, and make any necessary adjustments to the treatment plan. Reviewing the asthma action plan helps in identifying triggers, proper use of medications, and when to seek medical help. Administering a dose of the rescue inhaler without assessing the current management plan may not address the underlying issue. Instructing the parents to increase the dose of the controller medication without proper evaluation can lead to inappropriate medication adjustments. Scheduling a follow-up appointment in one week is not the immediate action needed to address the child's current symptoms.
3. The nurse is instructing a 65-year-old female client diagnosed with osteoporosis. The most important instruction regarding exercise would be to
- A. Exercise by doing weight-bearing activities
- B. Exercise to reduce weight
- C. Avoid exercise activities that increase the risk of fracture
- D. Exercise to strengthen muscles and thereby protect bones
Correct answer: A
Rationale: The correct answer is A: Exercise by doing weight-bearing activities. Weight-bearing activities help strengthen bones and prevent further bone loss in clients with osteoporosis. This type of exercise includes activities like walking, dancing, and weightlifting, which help improve bone density. Choice B is incorrect because the primary focus should be on bone health, not weight reduction. Choice C is incorrect as avoiding all exercise activities that increase the risk of fracture can lead to muscle weakness and a decline in bone health. Choice D is also incorrect because while strengthening muscles is beneficial, the emphasis for osteoporosis management should be on weight-bearing exercises specifically.
4. The nurse is caring for a client with fluid overload. The most reliable indicator of fluid volume status is
- A. Body weight
- B. Intake and output
- C. Daily weight
- D. Skin turgor
Correct answer: C
Rationale: Daily weight is the most reliable indicator of fluid volume status as it reflects changes in body fluid balance accurately. Body weight alone can fluctuate due to various factors, including food intake and bowel movements, which may not accurately represent fluid status. Intake and output provide information on fluid balance over time but may not reflect immediate changes. Skin turgor is a physical assessment finding that indicates hydration status, not overall fluid volume status.
5. A client with end-stage renal disease (ESRD) is scheduled for hemodialysis. Which laboratory value should be closely monitored before the procedure?
- A. Serum creatinine of 2.0 mg/dl
- B. Serum potassium of 5.5 mEq/L
- C. Serum calcium of 8.0 mg/dl
- D. Hemoglobin of 12 g/dl
Correct answer: B
Rationale: A serum potassium level of 5.5 mEq/L is concerning in a client with ESRD scheduled for hemodialysis as it indicates hyperkalemia, which can lead to serious cardiac complications. Hyperkalemia can be exacerbated during hemodialysis, making it crucial to closely monitor serum potassium levels before the procedure. Monitoring serum creatinine, serum calcium, or hemoglobin levels is important in managing ESRD but is not the immediate focus before hemodialysis. Therefore, option B is the correct choice.