HESI RN
HESI Fundamentals Practice Exam
1. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client’s blood pressure and pulse
Correct answer: D
Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.
2. A client is suspected of being poisoned and presents with symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth. The nurse should consider these findings consistent with which potential bioterrorism agent?
- A. ricin
- B. botulism toxin
- C. sulfur mustard
- D. yersinia pestis
Correct answer: B
Rationale: The correct answer is B: botulism toxin. The symptoms described, including symmetric, descending flaccid paralysis, blurred vision, double vision, and dry mouth, are classic manifestations of botulism, which is caused by a toxin produced by Clostridium botulinum. This toxin affects the nervous system, leading to muscle weakness and paralysis. Choice A, ricin, typically presents with gastrointestinal symptoms and organ failure. Choice C, sulfur mustard, causes blistering skin and respiratory issues. Choice D, yersinia pestis, is associated with the plague and presents with fever, chills, weakness, and swollen lymph nodes.
3. The home health nurse is preparing to make daily visits to a group of clients. Which client should the nurse visit first?
- A. A client with congestive heart failure who reports a 3-pound weight gain in the last two days
- B. A client with a healing surgical wound
- C. A client requiring wound dressing change
- D. A client with stable vital signs needing medication administration
Correct answer: A
Rationale: The correct answer is A. A 3-pound weight gain in two days indicates fluid retention and worsening heart failure, which requires immediate assessment. This could be a sign of decompensation in the client's condition, necessitating prompt evaluation and intervention. Choices B, C, and D do not present an immediate threat to the client's health and can be addressed after assessing the client with congestive heart failure.
4. A one-day-old neonate develops a cephalohematoma. The nurse should closely assess this neonate for which common complication?
- A. Jaundice.
- B. Poor feeding.
- C. Brain injury.
- D. Hypoglycemia.
Correct answer: A
Rationale: A cephalohematoma is a collection of blood between the skull and the periosteum. As the blood breaks down, there is an increased risk of jaundice due to the release of bilirubin from the breakdown of red blood cells. Jaundice is a common complication associated with cephalohematoma in neonates. Therefore, the nurse should closely monitor the neonate for signs of jaundice and manage it accordingly.
5. In the critical care unit, which client should receive the most care hours by a registered nurse (RN)?
- A. A client with a newly inserted Foley catheter and Alzheimer's disease
- B. A 55-year-old with chronic kidney disease
- C. An 82-year-old client with a newly fractured femur and soft wrist restraints
- D. A 72-year-old with pneumonia and sepsis on antibiotics
Correct answer: C
Rationale: The client with a newly fractured femur and soft wrist restraints should receive the most care hours as they have physical limitations due to the fracture and mental limitations due to being restrained. This client requires continuous monitoring, support, and frequent assessments to prevent complications. Choices A, B, and D do not have the same level of physical and mental care needs as the client with the newly fractured femur and soft wrist restraints.