HESI RN
HESI Fundamentals Practice Exam
1. What assessment finding places a client at risk for problems associated with impaired skin integrity?
- A. Scattered macules on the face
- B. Capillary refill of 5 seconds
- C. Smooth nail texture
- D. Presence of skin tenting
Correct answer: B
Rationale: The correct answer is B. A capillary refill time greater than 3 seconds indicates poor perfusion, leading to impaired skin integrity. Delayed capillary refill can compromise blood flow to the skin, increasing the risk of pressure ulcers or wounds due to reduced tissue perfusion. Choices A, C, and D are incorrect because scattered macules on the face, smooth nail texture, and presence of skin tenting are not direct indicators of impaired skin integrity or risk for skin problems.
2. The nurse is preparing to give a dose of a cephalosporin medication to a patient who has been receiving the antibiotic for 2 weeks. The nurse notes ulcers on the patient’s tongue and buccal mucosa. Which action will the nurse take?
- A. Hold the drug and notify the provider.
- B. Obtain an order to culture the oral lesions.
- C. Gather emergency equipment to prepare for anaphylaxis.
- D. Report a possible superinfection side effect of the cephalosporin.
Correct answer: D
Rationale: The nurse should report a possible superinfection side effect of the cephalosporin to the physician as the patient's symptoms may indicate a superinfection that requires treatment. Holding the drug is not necessary unless directed by the provider. Culturing the lesions is not indicated for this situation. There is no evidence to suggest impending anaphylaxis based on the patient's symptoms.
3. Which assessment finding should the healthcare provider identify as most concerning in a child with acute glomerulonephritis?
- A. Hypertension.
- B. Gross hematuria.
- C. Proteinuria.
- D. Periorbital edema.
Correct answer: A
Rationale: In a child with acute glomerulonephritis, hypertension is the most concerning assessment finding as it can indicate worsening renal function. Hypertension is a common complication of glomerulonephritis and can lead to further kidney damage if not managed promptly. Monitoring and controlling blood pressure is crucial in these cases to prevent complications and preserve renal function. Gross hematuria, proteinuria, and periorbital edema are also common findings in acute glomerulonephritis but hypertension poses a higher risk for renal damage if left uncontrolled.
4. A client with cirrhosis is experiencing ascites and peripheral edema. What is the nurse's priority intervention?
- A. Administer furosemide as prescribed.
- B. Administer albumin to increase oncotic pressure.
- C. Elevate the client's legs to reduce swelling.
- D. Administer a sodium-restricted diet.
Correct answer: A
Rationale: The correct answer is A: Administer furosemide as prescribed. Administering furosemide, a loop diuretic, is the priority intervention in a client with cirrhosis experiencing ascites and peripheral edema. Furosemide helps promote diuresis and reduce fluid buildup in the body. Choice B, administering albumin to increase oncotic pressure, may be beneficial in some cases but is not the priority intervention for immediate fluid removal. Elevating the client's legs (Choice C) and administering a sodium-restricted diet (Choice D) are important aspects of managing edema and ascites but are not the priority interventions in this situation.
5. A nurse contacts the healthcare provider after reviewing a client’s laboratory results and noting a blood urea nitrogen (BUN) of 35 mg/dL and a creatinine of 1.0 mg/dL. For which action should the nurse recommend a prescription?
- A. Intravenous fluids
- B. Hemodialysis
- C. Fluid restriction
- D. Urine culture and sensitivity
Correct answer: A
Rationale: The normal range for BUN is 10 to 20 mg/dL, and for creatinine, it is 0.6 to 1.2 mg/dL in males and 0.5 to 1.1 mg/dL in females. Creatinine is a more specific marker for kidney function compared to BUN. In this case, the client's creatinine level is within the normal range, indicating a non-renal cause for the elevated BUN. Dehydration is a common cause of increased BUN, so the appropriate action would be to recommend intravenous fluids to address the dehydration. Fluid restriction is not indicated as the client needs hydration. Hemodialysis is not appropriate for dehydration and is typically reserved for renal failure. The laboratory results do not suggest an infection, making a urine culture and sensitivity unnecessary in this scenario.