the nurse counts an adults apical heartbeat at 110 beats per minute the nurse describes this as
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Nursing Elites

HESI RN

HESI Fundamentals Practice Test

1. The healthcare professional counts an adult's apical heartbeat at 110 beats per minute. The healthcare professional describes this as:

Correct answer: C

Rationale: Tachycardia is a heart rate greater than 100 beats per minute. In this case, an adult's heart rate of 110 beats per minute falls within the range of tachycardia. Tachycardia can be a common physiological response to various stresses on the body, leading to an increased heart rate. Asystole refers to the absence of cardiac activity, bigeminy is a specific heart rhythm pattern, and bradycardia is a heart rate below 60 beats per minute in adults.

2. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

3. While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?

Correct answer: A

Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.

4. During the assessment, a client receiving a continuous infusion of heparin for deep vein thrombosis (DVT) is found to have a nosebleed. Which finding requires immediate action?

Correct answer: B

Rationale: A nosebleed (B) in a client receiving heparin is a sign of heparin toxicity and requires immediate action. It indicates that the client is at risk of excessive bleeding. While a prolonged aPTT of 70 seconds (A) is worth monitoring, active bleeding takes precedence. Elevated blood pressure (C) and lightheadedness (D) are potential side effects of heparin but are not as urgently concerning as active bleeding.

5. 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?

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.

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