HESI RN
HESI Fundamentals Questions
Question 1 of 5
A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?
Correct Answer: D
Rationale: A temperature of 100.4�F (38�C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.
Question 2 of 5
A client being discharged with a prescription for the bronchodilator theophylline is instructed to take three doses of the medication each day. Since timed-release capsules are not available, which dosing schedule should the nurse advise the client to follow?
Correct Answer: B
Rationale: Theophylline should be administered on a regular around-the-clock schedule to provide the best bronchodilating effect and reduce the potential for adverse effects. The correct dosing schedule of 8 a.m., 4 p.m., and midnight ensures that the client receives consistent dosing throughout the day. Other options do not provide the necessary around-the-clock coverage. It's important to note that food may affect the absorption of the medication, which is why the dosing schedule should not be tied to meal times.
Question 3 of 5
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
Correct Answer: A
Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.
Question 4 of 5
A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?
Correct Answer: A
Rationale: Administering oxygen via a non-rebreather mask is the priority intervention for a client with pulmonary edema to improve oxygenation and address respiratory distress. Adequate oxygenation is essential to support vital organ function. Administering furosemide intravenously, inserting a Foley catheter to monitor urine output, and positioning the client in a high Fowler's position are important interventions but are secondary to ensuring optimal oxygenation in this client with pulmonary edema.
Question 5 of 5
When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
Correct Answer: C
Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.
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