HESI RN
HESI Fundamentals Practice Exam
1. After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?
- A. Semi-Fowler's
- B. Prone
- C. Supine
- D. Sim's
Correct answer: A
Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.
2. What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?
- A. Do not allow visitors until precautions are discontinued
- B. Wear sterile gloves when handling the client’s body fluids
- C. Have the client wear a mask whenever someone enters the room
- D. Don a gown and gloves when entering the room
Correct answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the client's room. This precaution is essential to prevent the spread of MRSA and protect both the client and the healthcare worker from potential infection. Choice A is incorrect because visitors should not be restricted solely based on contact precautions. Choice B is incorrect as wearing sterile gloves is not necessary, standard precautions with regular gloves are sufficient. Choice C is incorrect because the client wearing a mask is not a standard practice for contact precautions; it is the healthcare worker who should take preventive measures.
3. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?
- A. Ask the nursing supervisor to meet with the student.
- B. Notify the student's clinical instructor of the situation.
- C. Ask the student if permission was obtained from the client.
- D. Explain that the records are hospital property and may not be removed.
Correct answer: D
Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.
4. During the insertion of a nasogastric tube (NGT), the client begins to cough and gag. What action should the healthcare professional take?
- A. Stop advancing the tube and allow the client to rest
- B. Remove the tube and try again after a few minutes
- C. Continue inserting the tube while the client sips water
- D. Withdraw the tube slightly and pause before continuing
Correct answer: D
Rationale: When a client begins to cough and gag during the insertion of a nasogastric tube, withdrawing the tube slightly and pausing is the appropriate action. This technique helps prevent further irritation, gives the client a moment to recover, and allows for a smoother continuation of the insertion process. Choice A is incorrect because allowing the client to rest without adjusting the tube position might not address the issue. Choice B is incorrect as removing the tube without addressing the cause of coughing and gagging may lead to repeated discomfort. Choice C is incorrect as continuing to insert the tube while the client is experiencing difficulties can increase discomfort and potential complications.
5. The nurse determines that a postoperative client's respiratory rate has increased from 18 to 24 breaths/min. Based on this assessment finding, which intervention is most important for the nurse to implement?
- A. Encourage the client to increase ambulation in the room.
- B. Offer the client a high-carbohydrate snack for energy.
- C. Force fluids to thin the client's pulmonary secretions.
- D. Determine if pain is causing the client's tachypnea.
Correct answer: D
Rationale: An increased respiratory rate can be a sign of various issues postoperatively, including pain. Assessing and managing pain is crucial as it can lead to tachypnea. Pain, anxiety, and fluid accumulation in the lungs can all contribute to an increased respiratory rate. Therefore, determining if pain is causing the tachypnea is the most important intervention to address the underlying cause. Encouraging ambulation, offering snacks, or forcing fluids are not the priority in this situation as pain assessment takes precedence in managing the increased respiratory rate.
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