HESI RN
HESI Fundamentals Practice Exam
1. A client is admitted with a diagnosis of left-sided heart failure. Which assessment finding is most consistent with this diagnosis?
- A. Dependent edema.
- B. Ascites.
- C. Nocturia.
- D. Orthopnea.
Correct answer: D
Rationale: Orthopnea (D) is most consistent with left-sided heart failure. It is characterized by difficulty breathing when lying flat and is relieved by sitting up or standing. Dependent edema (A), ascites (B), and nocturia (C) are more commonly associated with right-sided heart failure. Dependent edema refers to swelling due to fluid accumulation, ascites is the accumulation of fluid in the peritoneal cavity, and nocturia is the excessive need to urinate during the night, all of which are more indicative of right-sided heart failure.
2. 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.
3. A client is admitted with a fever of unknown origin. To assess fever patterns, which intervention should the nurse implement?
- A. Document the client’s temperature fluctuations
- B. Assess for flushed, warm skin consistently
- C. Measure temperature at regular intervals
- D. Use different sites for temperature measurement
Correct answer: C
Rationale: To assess fever patterns accurately, the nurse should measure the client’s temperature at regular intervals. This approach helps in identifying the pattern of fever spikes and fluctuations, which can provide valuable information for diagnostic and treatment purposes. Assessing for flushed, warm skin or documenting circadian rhythms may not directly reveal the fever pattern, while varying temperature measurement sites could lead to inconsistent readings. Therefore, measuring temperature at regular intervals is the most appropriate intervention to identify fever patterns in this scenario.
4. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?
- A. Administer sublingual nitroglycerin
- B. Obtain a 12-lead electrocardiogram (ECG)
- C. Apply oxygen via nasal cannula
- D. Initiate continuous cardiac monitoring
Correct answer: C
Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.
5. In completing a client's preoperative routine, the nurse finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
- A. Witness the client's signature on the permit.
- B. Answer the client's questions about the surgery.
- C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
- D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
Correct answer: C
Rationale: The nurse should inform the surgeon promptly that the operative permit is not signed and the client has questions about the surgery. It is crucial for the surgeon to be aware of these issues as it is their responsibility to explain the procedure to the client and ensure that the necessary consent is obtained before proceeding with the surgery. Answering the client's questions directly (choice B) may not be appropriate as the surgeon is the one responsible for providing detailed information about the procedure. Witnessing the client's signature (choice A) is premature since the permit is not signed. Reassuring the client (choice D) is not the most appropriate action at this point; the priority is to involve the surgeon in addressing the unsigned permit and the client's questions.
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