HESI RN
HESI Fundamentals Practice Exam
1. During evacuation of a group of clients from a medical unit because of a fire, the nurse observes an ambulatory client walking alone toward the stairway at the end of the hall. Which action should the nurse take?
- A. Assign an unlicensed assistive personnel to transport the client via a wheelchair.
- B. Remind the client to walk carefully down the stairs until reaching a lower floor.
- C. Ask the client to help by assisting a wheelchair-bound client to a nearby elevator.
- D. Open the closest fire doors to facilitate the evacuation of ambulatory clients.
Correct answer: B
Rationale: During a fire evacuation, it is crucial for ambulatory clients to be reminded to walk carefully down the stairs. This helps ensure the safety of the client by preventing falls or injuries during the evacuation process. Directing the client to proceed cautiously down the stairs until reaching a lower floor provides necessary guidance to promote a safe evacuation process. Choice A is incorrect because assigning unlicensed assistive personnel to transport the client via a wheelchair may delay the evacuation process and increase the risk of injury. Choice C is incorrect as it distracts the ambulatory client from evacuating safely by involving them in assisting another client. Choice D is incorrect as opening fire doors may not be the most appropriate action at that moment; prioritizing safe evacuation procedures for ambulatory clients is essential.
2. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?
- A. Oliguria.
- B. Kussmaul respirations.
- C. Fruity odor on the breath.
- D. Blood glucose level of 250 mg/dL.
Correct answer: B
Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.
3. The client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
- A. Observe the appearance of the skin under the ice pack.
- B. Instruct the client regarding the importance of the covering.
- C. Reapply the covering after filling it with fresh ice.
- D. Ask the client how long the ice pack was applied to the skin.
Correct answer: A
Rationale: The primary action for the nurse is to assess the skin under the ice pack to check for any potential thermal injury. This assessment is crucial to ensure the client's safety. Once the skin assessment is done and no harm is found, the nurse can proceed with other necessary actions such as providing instructions to the client or replacing the covering with fresh ice.
4. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?
- A. Provide an interpreter to convey the meaning of words and messages in translation
- B. Commend the client for her patience during a long wait in the admission process
- C. Arrange for the hospital chaplain to visit the client during her hospital stay
- D. Rely on cultural norms as the basis for providing healthcare for this client
Correct answer: D
Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.
5. During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
- A. The occurrence of any episodes of sleep apnea
- B. The child's blood pressure, pulse, and respirations
- C. Length of rapid eye movement (REM) sleep that the child is experiencing
- D. Description of the family's home environment
Correct answer: D
Rationale: In response to the mother's report, the nurse should assess the family's home environment first to identify any factors that may hinder the establishment of bedtime routines conducive to sleep. Factors such as noise, light, distractions, or other environmental aspects could be contributing to the child's difficulty falling asleep at a reasonable hour and waking up in the morning.
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