HESI Fundamentals Practice Exam

Correct Answer: A

Rationale: When a person is struck by lightning, it can cause an electrical shock that may affect the heart rhythm. Therefore, assessing pulse characteristics is crucial as lightning can act as a natural defibrillator. Monitoring the pulse rate and regularity will help determine if there are any cardiac abnormalities that need immediate attention. Open airway, entrance and exit wounds, and cervical spine injury assessments are also important but assessing pulse characteristics takes precedence in this situation to address potential cardiac issues.

Correct Answer: B

Rationale: The correct answer is B: Serum potassium level. Sodium polystyrene sulfonate (Kayexalate) is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestines, leading to potassium removal from the body. Monitoring the serum potassium level allows the nurse to assess the effectiveness of this medication in lowering the elevated potassium levels. Serum sodium (A), calcium (C), and glucose (D) levels are not directly impacted by the action of sodium polystyrene sulfonate.

Correct Answer: A

Rationale: When a person is struck by lightning, it can cause an electrical shock that may affect the heart rhythm. Therefore, assessing pulse characteristics is crucial as lightning can act as a natural defibrillator. Monitoring the pulse rate and regularity will help determine if there are any cardiac abnormalities that need immediate attention. Open airway, entrance and exit wounds, and cervical spine injury assessments are also important but assessing pulse characteristics takes precedence in this situation to address potential cardiac issues.

Correct Answer: C

Rationale: Limiting saturated fat from animal food sources to no more than 4 ounces per week is an important diet modification for lowering cholesterol. To be effective in reducing cholesterol, the client should exercise 30 minutes per day, or at least 4 to 6 times per week. Red meat and all proteins do not need to be eliminated to lower cholesterol, but should be restricted to lean cuts of red meat and smaller portions. The low density lipoproteins need to decrease rather than increase.

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.