HESI RN Fundamentals Exam

Question 1: View

Twelve hours following a unilateral total knee replacement, a client reports being unable to sleep because of severe incisional pain. What is the best initial nursing action?

A. Instruct the client in use of the prescribed patient-controlled analgesia (PCA) pump. B. Assist the client in assuming a lateral recumbent position for comfort. C. Initiate continuous passive motion (CPM) to relieve muscle spasms. D. Apply ice to the incision for twenty minutes prior to joint flexion exercises.

Explanation

A. Instructing the client in the use of the PCA pump directly addresses the severe pain by allowing the client to self-administer analgesia as needed, which provides immediate relief and is crucial for effective pain management post-surgery.
B. Assisting the client in changing positions may offer temporary relief but does not address the underlying pain, which should be managed primarily through medication.
C. Initiating CPM is not an appropriate first step for managing severe pain. CPM is used for improving joint mobility and should only be considered after effective pain management is established.
D. Applying ice might provide some temporary relief, but it is not a substitute for effective pain control through medication. Addressing the pain with PCA is the priority.

Question 2: View

When turning a male client who has been lying on his back for 2 hours, the nurse notes that the skin over his sacrum is very white. The client is repositioned and when the nurse reassesses the sacrum 2 hours later, the area is bright red. Which intervention should the nurse implement?

A. Apply a warm compress to the sacral area. B. Wash the area with soap and water. C. Reassess and turn the client in 30 minutes. D. Massage the reddened area with lotion.

Explanation

A. Applying a warm compress does not address the prevention of pressure ulcers and could potentially exacerbate skin issues. The primary focus should be on preventing further pressure.
B. Washing the area with soap and water does not effectively address the issue of pressure ulcer risk or the need for repositioning to alleviate pressure.
C. Reassessing and turning the client every 30 minutes helps prevent the development of pressure ulcers by relieving pressure on vulnerable areas, which is crucial for maintaining skin integrity.
D. Massaging the reddened area can cause further damage and is not recommended. Proper repositioning and pressure relief are the appropriate interventions.

Question 3: View

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

A. The technique is intended to maintain straight spinal alignment. B. Working together can decrease the risk of back injury to the nurses. C. Using two or three people increases client safety. D. Turning instead of pulling reduces the likelihood of skin damage.

Explanation

A. The log rolling technique is specifically intended to maintain straight spinal alignment, which is essential for preventing further injury or complications, particularly for patients with spinal injuries or undergoing post-surgical care. Proper spinal alignment is crucial during the turning process.
B. While working together can help decrease the risk of back injury for nurses, the primary purpose of the log rolling technique is to ensure the client’s spinal alignment.
C. Although using multiple people can enhance safety during the turning process, the main goal of the log rolling technique is to maintain spinal alignment rather than just increasing client safety.
D. Turning instead of pulling helps to reduce skin damage, but the primary reason for using the log rolling technique is to keep the spine aligned, not solely to address skin integrity.

Question 4: View

A client who is 2 days postoperative for thoracic surgery is reporting incisional pain 2 hours after receiving pain medication. The client rates the pain as 5 on a pain scale of 1 to 10. After placing a call to the healthcare provider, which action should the nurse implement?

A. Instruct the client to use guided imagery and slow rhythmic breathing. B. Place a hot water circulation device, such as an Aqua K pad, to the operative site. C. Tune to a television show or easy listening music to provide distraction. D. Provide at least 20 minutes of back massage and gentle effleurage.

Explanation

A. Guided imagery and slow rhythmic breathing are effective techniques for managing moderate pain and can help reduce the perception of pain by promoting relaxation. These methods can be used in conjunction with pain medication to enhance overall pain management.
B. Applying a hot water circulation device may not be appropriate for postoperative pain, as heat could interfere with healing or cause complications. The focus should be on pain management strategies that are safe for the surgical site.
C. While distraction methods like television or music can help, they are generally less effective for managing moderate pain compared to relaxation techniques and additional pain management strategies.
D. Providing a back massage may not be appropriate immediately after thoracic surgery, as it could cause discomfort or interfere with the surgical site. Effective pain management should prioritize safe and recommended interventions.

Question 5: View

The nurse is caring for a client with obstructive sleep apnea. The nurse should recognize the client is at greater risk for the development of which complication?

A. Hypothyroidism. B. Hypertension. C. Peptic ulcer disease. D. Fibromyalgia.

Explanation

A. Hypothyroidism is not directly related to obstructive sleep apnea. While sleep apnea can have various systemic effects, hypothyroidism is not a common complication associated with it.
B. Obstructive sleep apnea is strongly associated with an increased risk of hypertension. The repeated episodes of oxygen desaturation and arousal during sleep can contribute to increased blood pressure and cardiovascular strain.
C. Peptic ulcer disease is not a known complication of obstructive sleep apnea. It is generally associated with factors like H. pylori infection, NSAID use, and stress rather than sleep apnea.
D. Fibromyalgia is a chronic pain syndrome and is not typically associated with obstructive sleep apnea. Sleep apnea can exacerbate fatigue and sleep disturbances but does not directly cause fibromyalgia.

Question 6: View

The healthcare provider prescribes nasogastric tube (NGT) insertion for a client with a postoperative ileus. During insertion, the client begins to gag. Which action should the nurse take?

A. Use firm pressure to pass the tube through the glottis. B. Have the client tilt head backward to open the passage. C. Give the client a few sips of water to drink. D. Remove the tube and attempt reinsertion.

Explanation

A. Using firm pressure to pass the tube through the glottis can cause discomfort and potentially damage the client's airway. It is important to proceed with caution and avoid causing harm.
B. Tilting the head backward can actually make the insertion more difficult and increase the risk of gagging or aspiration. Proper head positioning typically involves slight flexion.
C. Giving the client sips of water is not recommended during NGT insertion as it can exacerbate gagging and increase the risk of aspiration.
D. Removing the tube and attempting reinsertion is the appropriate action if the client begins to gag. It allows the nurse to reposition the tube and attempt insertion more gently, ensuring the tube is correctly placed without causing undue discomfort or harm.

Question 7: View

The nurse receives a new prescription to administer oxygen at 3 L/minute via a nasal cannula to maintain an oxygen saturation between 90 and 100% for an adult client. The nurse obtains an oxygen saturation reading of 85% and, after repositioning the oximeter on a different finger, obtains a second reading of 87%. Which action should the nurse take next?

A. Place the client in a Trendelenburg position. B. Document the second reading in the client record. C. Securely place the prongs of the cannula in the nostrils. D. Place the pulse oximeter on the client's earlobe.

Explanation

A. The Trendelenburg position is not appropriate for managing low oxygen saturation levels and may not address the underlying issue. This position is more commonly used for hypotension, not hypoxemia.
B. Documenting the reading is important for record-keeping but does not address the immediate concern of the client's low oxygen saturation levels.
C. Ensuring that the nasal cannula is securely placed in the nostrils is crucial for effective oxygen delivery. A loose or improperly positioned cannula can result in inadequate oxygenation, contributing to lower oxygen saturation readings.
D. While placing the pulse oximeter on the earlobe might provide a different reading, it is essential first to ensure that the current oxygen delivery system is functioning properly and the cannula is properly positioned.

Question 8: View

The healthcare provider prescribes cefixime oral suspension 200 mg by mouth twice a day for an older adult who has difficulty swallowing pills. The bottle is labeled, "Cefixime for Oral Suspension, USP 100 mg per 5 mL." How many mL should the nurse administer daily? (Enter numerical value only.)

Explanation

To calculate the total daily dose, we first need to determine the dose per administration:

Desired dose = 200 mg/dose
Concentration = 100 mg/5 mL

Volume (mL) = Desired dose (mg) / Concentration (mg/mL)

Volume = 200 mg / (100 mg/5 mL) = 10 mL

Now, calculate the total daily volume:

10 mL/dose 2 doses/day = 20 mL/day

Question 9: View

An older adult client is admitted to the medical unit following a fall at home. While undressing the client, the nurse observes that the client is wearing an adult diaper and skin breakdown is obvious over the sacral area. Which action should the nurse implement first?

A. Apply a barrier ointment to intact areas that may be exposed to moisture. B. Determine the size and depth of skin breakdown over the sacral area. C. Complete a functional assessment of the client's self-care abilities. D. Establish a toileting schedule to decrease episodes of incontinence.

Explanation

A. While applying a barrier ointment is important for preventing further skin breakdown, it does not address the immediate need to assess the severity of existing damage.
B. Determining the size and depth of skin breakdown is crucial for assessing the severity of the pressure injury and planning appropriate treatment. Accurate assessment helps in selecting the right interventions and monitoring the progression of the wound.
C. Completing a functional assessment of the client's self-care abilities is important for overall care planning but should follow the initial assessment of the skin breakdown to ensure immediate needs are addressed.
D. Establishing a toileting schedule is a preventive measure for future incontinence but does not address the current skin breakdown that needs immediate assessment and treatment.

Question 10: View

A client is requesting medicine for pain 30 minutes after receiving morphine sulfate 5 mg intravenously. Which intervention should the nurse implement next?

A. Ask the UAP to offer a backrub to the client. B. Reassess the client and the level of pain. C. Tell the client the medication needs more time to work. D. Encourage the client to focus on taking deep breaths.

Explanation

A. Asking a UAP to offer a backrub is not appropriate if the pain assessment indicates that the current pain management strategy is insufficient. The nurse needs to reassess the pain to determine the effectiveness of the medication and whether additional interventions are needed.
B. Reassessing the client and the level of pain is essential to evaluate the effectiveness of the morphine sulfate administered and to guide further pain management decisions. This step is crucial for understanding the client's current pain status and determining the next steps in pain management.
C. Telling the client that the medication needs more time to work does not address the client's immediate concern or pain relief. Reassessing pain and potentially adjusting the treatment plan is more appropriate.
D. Encouraging deep breathing may help with pain management but does not address the need for further assessment of the pain level or potential adjustment in medication. Reassessing pain is the priority.