HESI RN
HESI Fundamentals Practice Test
1. The healthcare professional in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the healthcare professional implement?
- A. Communicate the colleague’s actions to the unit charge nurse
- B. Send an email to facility administration reporting the action
- C. Write an anonymous complaint to a professional website
- D. Post a comment about the action on a staff discussion board
Correct answer: A
Rationale: Observing a colleague accessing a patient's EHR without a legitimate reason is a violation of HIPAA, which protects patient confidentiality. The appropriate action in this scenario is to communicate the colleague’s actions to the unit charge nurse immediately. The charge nurse can then address the issue internally and ensure that patient privacy is maintained. Reporting the incident through the appropriate channels within the healthcare facility is the most effective and professional way to handle such breaches of patient confidentiality. Choices B, C, and D are incorrect because they do not involve addressing the issue internally within the healthcare facility. Reporting such incidents internally is essential to ensure that patient privacy is protected, and the matter is handled appropriately by healthcare authorities.
2. The nurse is planning a health fair for young adults. Which action is most important for the nurse to implement?
- A. Provide educational materials on smoking cessation
- B. Offer blood pressure screening and monitoring
- C. Provide information on safe sex practices
- D. Discuss the importance of a healthy diet and exercise
Correct answer: B
Rationale: Offering blood pressure screening and monitoring is crucial for young adults as it helps in the early detection and management of hypertension, a condition that often goes unnoticed. High blood pressure can lead to serious health issues if left untreated. While education on smoking cessation, safe sex practices, healthy diet, and exercise are important aspects of overall health promotion, blood pressure screening takes precedence due to its immediate impact on health and the prevention of potential complications.
3. Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?
- A. Ask the family to wait in the cafeteria while the next of kin makes the necessary arrangements
- B. Provide space and privacy for the family to share their concerns about the client’s discharge
- C. Ask the social worker to encourage the family to clear the hallway
- D. Explain to the family the client’s need for privacy so that she can make independent decisions
Correct answer: B
Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client’s discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.
4. A 3-year-old child with a high fever and sore throat is brought to the clinic. The nurse observes that the child is drooling and has difficulty swallowing. What is the nurse’s priority action?
- A. Administer antipyretic medication
- B. Prepare for emergency airway management
- C. Offer the child ice chips to suck on
- D. Assess the child’s hydration status
Correct answer: B
Rationale: In a 3-year-old child with drooling, difficulty swallowing, high fever, and sore throat, the nurse should prioritize preparing for emergency airway management. These signs may indicate epiglottitis, a condition that can quickly obstruct the airway, leading to respiratory distress and potentially fatal outcomes if not managed promptly. Administering antipyretic medication (Choice A) may be necessary later but is not the priority. Offering ice chips (Choice C) is contraindicated as the child has difficulty swallowing. Assessing hydration status (Choice D) is important but not the priority when the airway is at risk.
5. A male client who recently lost a loved one arrives at the mental health center and tells the nurse he is no longer interested in his usual activities and has not slept for several days. Which priority nursing problem should the nurse include in this client’s plan of care?
- A. Risk for suicide
- B. Sleep deprivation
- C. Situational low self-esteem
- D. Social isolation
Correct answer: A
Rationale: The correct answer is A: Risk for suicide. Considering the client's recent loss, lack of interest in activities, and sleep disturbances, the nurse should prioritize assessing and addressing the risk for suicide. This client is displaying warning signs such as loss of interest in usual activities and sleep disturbances, which are commonly associated with suicidal ideation. B: Sleep deprivation is not the priority issue in this scenario, as the client's lack of sleep is likely a symptom of a deeper emotional struggle. C: Situational low self-esteem and D: Social isolation may be concerns for this client but do not take precedence over the immediate risk of suicide, given the presented symptoms.