HESI RN
HESI Fundamentals Practice Test
1. The nurse is administering the 0900 medications to a client who was admitted during the night. Which client statement indicates that the nurse should further assess the medication order?
- A. At home I take my pills at 8:00 am.
- B. It costs a lot of money to buy all of these pills.
- C. I get so tired of taking pills every day.
- D. This is a new pill I have never taken before.
Correct answer: D
Rationale: The client's statement that 'This is a new pill I have never taken before' indicates the need for further assessment by the nurse to ensure the medication is correct and safe. Choices A, B, and C do not raise immediate concerns about the medication order; therefore, they are incorrect. Choice A simply provides information about the client's usual medication schedule, choice B is related to the cost of the pills, and choice C expresses fatigue from taking pills, but none of these statements suggest a potential issue with the new medication.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 liters per minute by nasal cannula. The client develops respiratory distress and the nurse increases the oxygen to 4 liters per minute. Shortly afterward, the client becomes lethargic and confused. What action should the nurse take first?
- A. Reposition the nasal cannula
- B. Lower the oxygen rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct answer: B
Rationale: In this scenario, the client with COPD receiving increased oxygen is experiencing oxygen toxicity, leading to lethargy and confusion. Lowering the oxygen rate is the priority action to prevent further harm. Repositioning the nasal cannula, encouraging coughing and deep breathing, and monitoring oxygen saturation are all important interventions, but the immediate concern is to address the oxygen toxicity by lowering the oxygen rate.
3. A client with a history of atrial fibrillation is prescribed warfarin (Coumadin). Which laboratory value should the nurse monitor closely?
- A. Prothrombin time (PT)
- B. Hemoglobin level
- C. International Normalized Ratio (INR)
- D. Serum sodium level
Correct answer: C
Rationale: The correct answer is C, International Normalized Ratio (INR). The INR should be closely monitored in a client prescribed warfarin (Coumadin) to assess the effectiveness and safety of anticoagulation therapy. Monitoring the INR helps ensure that the client is within the therapeutic range for anticoagulation, reducing the risk of bleeding or clotting complications. Prothrombin time (A) is used to calculate the INR and monitor the effectiveness of warfarin therapy. Hemoglobin level (B) is important but not the primary lab value to monitor when a client is on warfarin. Serum sodium level (D) is not directly related to monitoring warfarin therapy.
4. Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children?
- A. Carefully recording the height and weight of children to detect inappropriate growth.
- B. Performing head circumference measurements on infants under one year of age.
- C. Assessing for behavioral problems at home and school by interviewing the parents.
- D. Noting tracked weight gain without a gain in height on a growth chart.
Correct answer: A
Rationale: Recording the height and weight of children is crucial in detecting growth abnormalities like hypopituitarism and hyperpituitarism. Inappropriate growth patterns, such as disproportionate weight gain or stunted height, can be indicative of these conditions. Regular monitoring of height and weight is a fundamental nursing intervention that can aid in the early identification and management of pituitary-related disorders in children.
5. The nurse is caring for a client with primary adrenal insufficiency (Addison's disease). Which of the following laboratory findings would the nurse expect?
- A. Hypernatremia
- B. Hyperkalemia
- C. Hyperglycemia
- D. Hypercalcemia
Correct answer: B
Rationale: In primary adrenal insufficiency (Addison's disease), there is a decrease in aldosterone levels, leading to sodium loss and potassium retention. This imbalance results in hyperkalemia, making choice B the correct answer. Hypernatremia (choice A) is unlikely due to sodium loss. Hyperglycemia (choice C) and hypercalcemia (choice D) are not typically associated with primary adrenal insufficiency.