HESI RN
HESI Fundamentals Practice Exam
1. While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take?
- A. Remove the basin of water from the client’s bed immediately
- B. Remind the UAP to dry between the client’s toes completely
- C. Advise the UAP that this procedure may lead to skin damage
- D. Add skin cream to the basin of water while the foot is soaking
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client’s toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.
2. Which of the following is a group of three RNA nucleotides?
- A. A stop codon
- B. A codon
- C. An anticodon
- D. tRNA
Correct answer: B
Rationale: The correct answer is B - A codon. A codon is a sequence of three RNA nucleotides that specifies a particular amino acid or a stop signal during protein synthesis. Choice A, a stop codon, is a sequence of three nucleotides that signals the termination of protein synthesis. Choice C, an anticodon, is a group of three nucleotides found in tRNA that pairs with the complementary codon in mRNA. Choice D, tRNA, stands for transfer RNA, which is a type of RNA that carries amino acids to the ribosome during protein synthesis.
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 full-term, 24-hour-old infant in the nursery regurgitates and suddenly turns cyanotic. What should the nurse do first?
- A. Suction the oral and nasal passages.
- B. Give oxygen by positive pressure.
- C. Stimulate the infant to cry.
- D. Turn the infant onto the right side.
Correct answer: A
Rationale: In a situation where an infant regurgitates and turns cyanotic, the priority action should be to clear any potential airway obstruction. Suctioning the oral and nasal passages is crucial to ensure the infant's airway is clear and allow for proper breathing. This intervention takes precedence over providing oxygen, stimulating the infant to cry, or repositioning the infant.
5. The nurse observes an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation following a transurethral resection of the prostate (TURP). What is the best initial nursing action?
- A. Provide additional oral fluid intake
- B. Measure the client's intake and output
- C. Increase the flow of the bladder irrigation
- D. Administer a PRN dose of an antispasmodic agent
Correct answer: C
Rationale: The best initial nursing action when observing an increased number of blood clots in the drainage tubing of a client with continuous bladder irrigation post-TURP is to increase the flow of the bladder irrigation. This action helps prevent blood clots from obstructing the catheter, ensuring effective drainage and promoting client comfort. Providing additional oral fluid intake (Choice A) is important for overall hydration but may not directly address the issue of blood clots in the drainage tubing. Measuring the client's intake and output (Choice B) is a routine nursing assessment that may not directly address the immediate concern of blood clots obstructing the catheter. Administering a PRN dose of an antispasmodic agent (Choice D) is not the best initial action as it does not directly address the issue of blood clots in the drainage tubing.