HESI RN
HESI Fundamentals Practice Test
1. When entering the room of an adult male, the nurse finds that the client is very anxious. Before providing care, what action should the nurse take first?
- A. Divert the client’s attention
- B. Call for additional help from staff
- C. Document the planned action
- D. Re-assess the client's situation
Correct answer: D
Rationale: Before providing care to an anxious client, it is crucial for the nurse to first re-assess the client's situation. By re-assessing, the nurse can understand the underlying cause of the client's anxiety, which will help in tailoring appropriate care interventions. Re-assessment ensures that care provided is individualized and addresses the client's specific needs, promoting effective and client-centered care delivery. Diverting the client’s attention (Choice A) may not address the root cause of the anxiety. Calling for additional help (Choice B) may be necessary in some situations but should not be the first action. Documenting the planned action (Choice C) should come after re-assessing the client's situation to ensure accurate documentation based on the current assessment.
2. The endometrial tissue of the cervix is arranged in folds known as:
- A. Racemose glands
- B. Rugae
- C. Arbor vitae
- D. Peritoneum
Correct answer: B
Rationale: The endometrial tissue of the cervix is arranged in folds known as rugae, not Arbor vitae. Rugae are commonly found in anatomical structures like the stomach and bladder to allow expansion. Choices A, C, and D are incorrect. Racemose glands refer to branched compound glands, Arbor vitae is the tree-like appearance of the cerebellum, and Peritoneum is the serous membrane lining the abdominal cavity.
3. 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.
4. A client with a history of chronic kidney disease (CKD) is admitted with hyperkalemia. Which assessment finding requires immediate intervention?
- A. Peaked T waves on the ECG
- B. Bradycardia
- C. Decreased deep tendon reflexes
- D. Muscle weakness
Correct answer: A
Rationale: Peaked T waves on the ECG are a critical finding in hyperkalemia as they indicate potential life-threatening cardiac arrhythmias. Immediate intervention is necessary to prevent cardiac complications such as ventricular tachycardia or fibrillation. Bradycardia, decreased deep tendon reflexes, and muscle weakness are not typically associated with hyperkalemia and do not pose the same level of immediate risk to the client's life.
5. A client with polycystic kidney disease (PKD is being assessed by a nurse. Which assessment finding should prompt the nurse to immediately contact the healthcare provider?
- A. Flank pain
- B. Periorbital edema
- C. Bloody and cloudy urine
- D. Enlarged abdomen
Correct answer: B
Rationale: Periorbital edema would not typically be associated with polycystic kidney disease (PKD) and could indicate other underlying issues that require immediate attention. Flank pain and an enlarged abdomen are common findings in PKD due to kidney enlargement and displacement of other organs. Bloody or cloudy urine can result from cyst rupture or infection, which are expected in PKD. Therefore, periorbital edema is the most alarming finding in this scenario and warrants prompt notification of the healthcare provider.