HESI RN
HESI Fundamentals Practice Test
1. The healthcare professional observes a UAP taking a client's blood pressure in the lower extremity. Which observation of this procedure requires the healthcare professional's intervention?
- A. The cuff wraps around the girth of the leg.
- B. The UAP auscultates the popliteal pulse with the cuff on the lower leg.
- C. The client is placed in a prone position.
- D. The systolic reading is 20 mm Hg higher than the blood pressure in the client's arm.
Correct answer: B
Rationale: When obtaining blood pressure in the lower extremities, the popliteal pulse is the site for auscultation when the blood pressure cuff is applied around the thigh. Auscultating the popliteal pulse with the cuff on the lower leg is incorrect as it may lead to an inaccurate reading. Placing the client in a prone position and wrapping the cuff around the girth of the leg are acceptable practices. A systolic reading that is 20 mm Hg higher in the lower extremity compared to the arm is expected due to the difference in blood pressure between the upper and lower parts of the body.
2. A client asks the nurse for information about reducing risk factors for BPH. Which information should the nurse provide?
- A. Increase physical activity
- B. Decrease alcohol consumption
- C. Reduce intake of dairy products
- D. Avoid caffeine and spicy foods
Correct answer: A
Rationale: The correct answer is A: Increase physical activity. Physical activity can help reduce the risk of benign prostatic hyperplasia (BPH) by improving overall circulation and reducing inflammation. While decreasing alcohol consumption and avoiding caffeine and spicy foods may help with symptom management, increasing physical activity is more strongly linked to the prevention of BPH.
3. The nurse is caring for a 2-day old neonate who has not passed meconium and has a swollen abdomen. The healthcare provider reviews the flat plate X-ray of the abdomen and makes a tentative diagnosis of Hirschsprung's disease. Which pathophysiological process is consistent with this neonate's clinical picture?
- A. The congenital absence of parasympathetic ganglion cells to large intestine produces no peristalsis.
- B. Pyloric obstruction causes reflux and projectile hematemesis.
- C. Partial imperforated anal opening limits passage of stools.
- D. Peristalsis moving against the intestinal obstruction causing hyperactivity of the bowel.
Correct answer: A
Rationale: Hirschsprung's disease is caused by the absence of parasympathetic ganglion cells in the large intestine, leading to a lack of peristalsis and obstruction.
4. The healthcare provider is preparing to administer methylergonovine maleate (Methergine) to a postpartum client. Based on what assessment finding should the healthcare provider withhold the drug?
- A. Respiratory rate of 22 breaths/min
- B. A large amount of lochia rubra
- C. Blood pressure 149/90
- D. Positive Homan’s sign
Correct answer: C
Rationale: A blood pressure of 149/90 is an indication to withhold Methergine due to its potential to further increase blood pressure. Methergine is a medication that can cause vasoconstriction, leading to elevated blood pressure. In this case, administering Methergine could exacerbate the elevated blood pressure, posing a risk to the patient. Therefore, it is crucial to withhold the medication in the presence of hypertension to prevent adverse effects. The other options are not directly related to the administration of Methergine. A respiratory rate of 22 breaths/min is within the normal range. A large amount of lochia rubra may indicate normal postpartum bleeding. A positive Homan’s sign is associated with deep vein thrombosis, which is not a contraindication for administering Methergine.
5. A client receiving nitrofurantoin (Macrodantin) calls the health care provider's office complaining of side effects related to the medication. Which side effect indicates the need to stop treatment with this medication?
- A. Nausea
- B. Diarrhea
- C. Anorexia
- D. Cough and chest pain
Correct answer: D
Rationale: Pulmonary reactions such as cough and chest pain are serious side effects associated with nitrofurantoin that require immediate discontinuation of the medication to prevent potential severe respiratory complications.