HESI RN
HESI Fundamentals Practice Test
1. When caring for an immobile client, what nursing diagnosis has the highest priority?
- A. Risk for fluid volume deficit.
- B. Impaired gas exchange.
- C. Risk for impaired skin integrity.
- D. Altered tissue perfusion.
Correct answer: B
Rationale: When caring for an immobile client, the nursing diagnosis with the highest priority is impaired gas exchange. This is because impaired gas exchange implies difficulty with breathing, which is essential for sustaining life. Adequate oxygenation is crucial for all bodily functions, and any impairment in gas exchange can lead to serious complications, making it the priority nursing diagnosis to address in an immobile client. Choices A, C, and D are important considerations as well when caring for an immobile client, but they are secondary to impaired gas exchange. Risk for fluid volume deficit may occur due to immobility, but ensuring proper gas exchange takes precedence as it directly impacts the client's immediate survival. Risk for impaired skin integrity is a concern in immobile clients but does not pose an immediate threat to life like impaired gas exchange. Altered tissue perfusion is also critical but is usually a consequence of impaired gas exchange, reinforcing the priority of addressing gas exchange first.
2. A client with a history of hypertension is admitted with a blood pressure of 200/120 mm Hg. Which medication should the nurse prepare to administer?
- A. Metoprolol (Lopressor).
- B. Furosemide (Lasix).
- C. Lisinopril (Zestril).
- D. Nitroprusside (Nipride).
Correct answer: D
Rationale: The correct answer is D, Nitroprusside (Nipride). In this scenario of severe hypertension (200/120 mm Hg), a hypertensive emergency is present, requiring rapid reduction of blood pressure. Nitroprusside is a vasodilator that acts quickly to lower blood pressure in such emergencies. Options A, B, and C are incorrect: A) Metoprolol is a beta-blocker that lowers blood pressure but is not indicated for hypertensive emergencies requiring rapid reduction. B) Furosemide is a diuretic that helps with fluid retention but does not rapidly lower blood pressure. C) Lisinopril is an ACE inhibitor used for long-term management of hypertension, not for immediate reduction in hypertensive emergencies.
3. The nurse is preparing to give trimethoprim-sulfamethoxazole (TMP-SMX) to a patient and notes a petechial rash on the patient’s extremities. The nurse will perform which action?
- A. Hold the dose and notify the provider.
- B. Request an order for a blood glucose level.
- C. Request an order for a BUN and creatinine level.
- D. Request an order for diphenhydramine (Benadryl).
Correct answer: A
Rationale: When a patient on TMP-SMX presents with a petechial rash, it can be indicative of a severe adverse reaction such as thrombocytopenia or a hypersensitivity reaction. The appropriate action for the nurse to take in this situation is to hold the dose of TMP-SMX and notify the healthcare provider immediately. This is crucial to prevent further administration of a medication that may be causing a serious adverse effect. Requesting a blood glucose level (Choice B) is not relevant in this scenario as the patient's presentation is suggestive of a skin-related issue rather than a glucose-related problem. Similarly, requesting a BUN and creatinine level (Choice C) would not address the immediate concern of a petechial rash and its association with TMP-SMX. Requesting an order for diphenhydramine (Choice D) may help manage itching or mild allergic reactions but is not the priority when a petechial rash is observed, as it may indicate a more severe reaction requiring immediate intervention.
4. The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother?
- A. Give small amounts of baby food with each feeding.
- B. Thicken formula with cereal for each feeding.
- C. Dilute the child's formula with equal parts of water.
- D. Offer 10% dextrose in water between most feedings.
Correct answer: B
Rationale: Thickening formula with cereal is a recommended intervention for infants with gastroesophageal reflux disease (GERD) to help reduce vomiting and increase caloric intake. This modification can help the infant keep the food down better, reducing reflux symptoms while providing adequate nutrition. Giving small amounts of baby food with each feeding (Choice A) is not recommended for a 5-month-old with GERD as it may exacerbate symptoms. Diluting the child's formula with equal parts of water (Choice C) can lead to inadequate nutrition and is not advisable. Offering 10% dextrose in water between most feedings (Choice D) is not appropriate for managing GERD in infants and does not address the underlying issue of reflux.
5. Which of the following is not found in a prokaryotic cell?
- A. Plasma membrane
- B. Cytoplasm
- C. Nucleus
- D. Ribosomes
Correct answer: C
Rationale: The correct answer is C, 'Nucleus.' Prokaryotic cells do not have a defined nucleus, unlike eukaryotic cells. The plasma membrane, cytoplasm, and ribosomes are all components found in prokaryotic cells. The plasma membrane surrounds the cell and regulates what enters and exits, the cytoplasm is the gel-like substance that fills the cell, and ribosomes are responsible for protein synthesis.