HESI RN
HESI Fundamentals Practice Exam
1. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
- A. Witness the client's signature on the permit.
- B. Answer the client's questions about the surgery.
- C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
- D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
Correct answer: C
Rationale: The nurse should inform the surgeon promptly that the operative permit is not signed and the client has questions about the surgery. It is crucial for the surgeon to be aware of these issues as it is their responsibility to explain the procedure to the client and ensure that the necessary consent is obtained before proceeding with the surgery. Answering the client's questions directly (choice B) may not be appropriate as the surgeon is the one responsible for providing detailed information about the procedure. Witnessing the client's signature (choice A) is premature since the permit is not signed. Reassuring the client (choice D) is not the most appropriate action at this point; the priority is to involve the surgeon in addressing the unsigned permit and the client's questions.
2. A patient asks the nurse about taking calcium supplements to avoid hypocalcemia. The nurse will suggest that the patient follow which instruction?
- A. Take a calcium and vitamin D combination supplement.
- B. Take calcium along with phosphorus to improve absorption.
- C. Take calcium with antacids to reduce stomach upset.
- D. Use aspirin instead of acetaminophen when taking calcium.
Correct answer: A
Rationale: The correct answer is to take a calcium and vitamin D combination supplement. Vitamin D enhances the absorption of calcium in the body, making it an essential component for calcium utilization. Choice B is incorrect because calcium and phosphorus have an inverse relationship, where an increased level of one mineral decreases the level of the other, so taking them together may not be beneficial. Choice C is incorrect because antacids often contain magnesium, which can promote calcium loss instead of absorption. Choice D is incorrect because aspirin can alter vitamin D levels and interfere with calcium absorption, so it is not recommended when taking calcium supplements.
3. At 39-weeks gestation, a multigravida is having a nonstress test (NST), the fetal heart rate (FHR) has remained non-reactive during 30 minutes of evaluation. Based on this finding, which action should the nurse implement?
- A. Initiate an intravenous infusion.
- B. Observe the FHR pattern for 30 more minutes.
- C. Schedule a biophysical profile.
- D. Place an acoustic stimulator on the abdomen.
Correct answer: D
Rationale: In cases where the fetal heart rate remains non-reactive during an NST, using an acoustic stimulator on the abdomen can help stimulate fetal movement and promote heart rate reactivity. This intervention aims to assess the fetus's well-being and response to external stimuli, which can provide valuable information about fetal health status.
4. When reassigned to the emergency department, a nurse should understand that gastric lavage is a priority in which situation?
- A. An infant who has been identified to have botulism
- B. A toddler who ate a number of ibuprofen tablets
- C. A preschooler who swallowed powdered plant food
- D. A school-aged child who took a handful of vitamins
Correct answer: A
Rationale: The correct answer is A because gastric lavage is a priority for infants with botulism to remove toxins from the stomach. Botulism is a serious condition caused by a toxin produced by Clostridium botulinum bacteria. Gastric lavage helps in removing the toxin from the stomach. Choice B is incorrect because gastric lavage is not typically indicated for ibuprofen ingestion. Choice C is incorrect because gastric lavage is not the first-line treatment for ingesting powdered plant food. Choice D is incorrect because gastric lavage is not routinely performed for vitamin ingestion.
5. A client who is receiving intravenous heparin therapy has an activated partial thromboplastin time (aPTT) of 90 seconds. Which action should the nurse take?
- A. Continue the heparin infusion as prescribed.
- B. Decrease the heparin infusion rate.
- C. Increase the heparin infusion rate.
- D. Stop the heparin infusion and notify the healthcare provider.
Correct answer: D
Rationale: An aPTT of 90 seconds is significantly elevated, indicating a high risk of bleeding due to excessive anticoagulation. In this case, the heparin infusion should be stopped immediately to prevent further anticoagulation and an increased bleeding risk. Notifying the healthcare provider is essential to discuss alternative anticoagulation strategies or interventions. Continuing heparin therapy without action could lead to severe bleeding complications. Decreasing or increasing the heparin infusion rate would exacerbate the risk of bleeding, making options A, B, and C incorrect.