HESI Fundamentals Practice Questions

Correct Answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

Correct Answer: B

Rationale: The presence of a non-blanching red area over the client's trochanter is a concerning finding as it indicates possible pressure ulcer formation. This finding necessitates an increase in the frequency of position changes to prevent skin breakdown. Choices A, C, and D do not directly correlate with the need for increased position changes. A flat rash, ecchymosis, and petechiae may have different causes and would not be addressed by changing the client's position more frequently.

Correct Answer: A

Rationale: The correct answer is A: Temperature. A high temperature of 39.2�C (102�F) indicates a fever, which can be a sign of infection or another serious condition. Investigating the cause of the fever is a priority to address any underlying health issue promptly. Menses overdue (choice B) could be relevant but is not as urgent as addressing a fever. A soft tender abdomen (choice C) is important but may be a consequence of the underlying condition causing the fever. Heart rate (choice D) is also significant, but the priority here is to identify the cause of the fever.

Correct Answer: B

Rationale: Cyanosis, a bluish discoloration of the skin, indicates inadequate oxygenation and requires immediate intervention. It suggests a severe lack of oxygen in the blood, which can be life-threatening. Pallor and jaundice are concerning findings but may not indicate an immediate life-threatening situation. Pallor can be a sign of anemia or low blood pressure, while jaundice may indicate liver dysfunction. Erythema, which is redness of the skin, is typically not an emergency and can be caused by various factors such as inflammation or increased blood flow to the area.

Correct Answer: D

Rationale: The presence of blood in the urine in a client with a urinary tract infection (UTI) may indicate a more severe infection, such as pyelonephritis, or complications like kidney stones or bladder cancer. Therefore, this finding should be reported immediately for further evaluation and management. Cloudy urine, burning sensation during urination, and foul-smelling urine are common symptoms of UTI and may not necessarily signify an urgent need for immediate reporting compared to the presence of blood in the urine.