HESI Practice Test for Fundamentals

Correct Answer: D

Rationale: The correct answer is D. Turning a patient's head with a neck injury to the side when giving oral care can lead to harm or further injury. The neck should be kept in a neutral position to prevent exacerbation of the injury. Choices A, B, and C are not actions that require immediate nurse intervention. Not offering a backrub, not washing a patient's hair, or turning off the television are not critical issues that pose harm to the patient's well-being or safety.

Correct Answer: A

Rationale: It is important for the nurse to address their feelings of reluctance when dealing with a manipulative client by discussing them with an objective peer or supervisor. This action can provide valuable insight and support for managing the nurse-client relationship. Choice B should be avoided as limiting contacts with the client may not address the underlying issues and could potentially harm the therapeutic relationship. Choice C is confrontational and may escalate the situation rather than resolve it. Choice D, while important, should come after addressing the nurse's feelings and seeking support.

Correct Answer: B

Rationale: The correct answer is B, which is low-molecular-weight heparin doses. After hip replacement surgery, patients are at risk of developing deep vein thrombosis (DVT) due to immobility. Heparin and low-molecular-weight heparin are commonly used for prophylaxis against DVT. Monitoring for hemorrhage is crucial when administering anticoagulants. Choices A, C, and D are not directly related to monitoring for hemorrhage in this scenario. Thick, tenacious pulmonary secretions (Choice A) may indicate respiratory issues, SCDs (Choice C) help prevent DVT but do not directly relate to hemorrhage monitoring, and elastic stockings (TED hose) (Choice D) are used for DVT prophylaxis but do not alert to hemorrhage.

Correct Answer: B

Rationale: The correct instruction for using a metered-dose inhaler is to hold your breath for 10 seconds after inhaling the medication. This allows the medication to be absorbed more effectively in the lungs. Inhaling quickly and deeply while pressing down on the inhaler (Choice A) may cause the medication to deposit in the mouth and throat rather than reaching the lungs. Exhaling immediately after inhaling the medication (Choice C) may also lead to medication wastage. Shaking the inhaler before each use (Choice D) is not necessary for all types of inhalers and can sometimes cause improper drug delivery.

Correct Answer: A

Rationale: Yellowing of the skin and eyes (jaundice) is a classic sign of liver dysfunction in clients with cirrhosis. Jaundice indicates the accumulation of bilirubin in the body due to impaired liver function. This finding suggests worsening liver damage and should be reported immediately to the healthcare provider for prompt evaluation and management. Dark-colored urine (choice B) is also a concerning symptom in liver disease, indicating possible bilirubin presence, but it is not as urgent as jaundice. Abdominal distention (choice C) and confusion (choice D) are common in cirrhosis but do not indicate an immediate need for healthcare provider notification compared to jajsondice.