HESI RN
HESI Fundamentals
1. When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?
- A. Loosen the right wrist restraint.
- B. Apply a pulse oximeter to the right hand.
- C. Compare hand color bilaterally.
- D. Palpate the right radial pulse.
Correct answer: A
Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.
2. The healthcare provider is monitoring a client with Cushing's syndrome. Which of the following findings should be reported to the healthcare provider immediately?
- A. Hyperglycemia
- B. Hypertension
- C. Low-grade fever
- D. Weight gain
Correct answer: C
Rationale: In a client with Cushing's syndrome, a low-grade fever should be reported immediately as it may indicate an infection. Clients with Cushing's syndrome are immunosuppressed, making them more susceptible to infections. Hyperglycemia and hypertension are common findings in Cushing's syndrome and are managed as part of the condition. Weight gain is also a common symptom in Cushing's syndrome and may not require immediate reporting unless it is sudden and severe.
3. Which nursing diagnosis has the highest priority when planning care for a client in cardiogenic shock?
- A. Risk for imbalanced body temperature
- B. Excess fluid volume
- C. Fatigue
- D. Ineffective Tissue Perfusion
Correct answer: D
Rationale: In cardiogenic shock, the priority nursing diagnosis is Ineffective Tissue Perfusion. This diagnosis indicates that the client is not receiving adequate oxygenated blood to tissues, putting vital organs at risk. Addressing ineffective tissue perfusion is crucial to prevent organ damage and ensure the client's survival. The other options, such as 'Risk for imbalanced body temperature,' 'Excess fluid volume,' and 'Fatigue,' are important but secondary to the immediate threat of inadequate tissue perfusion in cardiogenic shock.
4. The nurse is assessing a newborn who was precipitously delivered at 38 weeks' gestation. The newborn is tremulous, tachycardic, and hypertensive. Which assessment action is most important for the nurse to take?
- A. Perform a gestational age assessment.
- B. Obtain a drug screen for cocaine.
- C. Determine reactivity of neonatal reflexes.
- D. Weigh and measure the newborn.
Correct answer: B
Rationale: The correct answer is to obtain a drug screen for cocaine. Tremulousness, tachycardia, and hypertension in a newborn can be signs of neonatal abstinence syndrome, often caused by maternal drug use, such as cocaine. Identifying maternal drug use is crucial for appropriate management and treatment of the newborn.
5. A client is admitted to the hospital with a diagnosis of pneumonia. The client is prescribed intravenous antibiotics and oxygen therapy. Which assessment finding indicates that the client's condition is improving?
- A. Increased white blood cell count
- B. Crackles heard on lung auscultation
- C. Productive cough with green sputum
- D. Decreased respiratory rate from 24 to 18 breaths per minute
Correct answer: D
Rationale: A decrease in respiratory rate indicates that the client's breathing is becoming more stable, which suggests an improvement in their condition. Respiratory rate is a critical indicator of respiratory status and oxygenation. Increased white blood cell count (choice A) suggests ongoing infection, crackles on lung auscultation (choice B) indicate fluid in the lungs, and productive cough with green sputum (choice C) may indicate persistent infection or airway inflammation, which do not necessarily reflect improvement in pneumonia.