HESI Fundamentals Practice Test

Questions 53

HESI RN

HESI RN Test Bank

HESI Fundamentals Practice Test Questions

Question 1 of 5

An older adult male client is admitted to the medical unit following a fall at home. When undressing him, the nurse notes that he is wearing an adult diaper, and skin breakdown is obvious over his sacral area. What action should the nurse implement first?

Correct Answer: D

Rationale: The initial step the nurse should take when faced with skin breakdown over the sacral area of the client is to determine the size and depth of the affected area. Assessing and documenting these aspects are crucial before initiating any treatment. This evaluation will guide the nurse in developing an appropriate care plan to address the skin breakdown effectively. Options A, B, and C are not the first steps to take in this situation. While establishing a toileting schedule and completing a functional assessment are important, assessing the size and depth of the skin breakdown is the priority to initiate proper treatment. Applying a barrier ointment without assessing the extent of the breakdown may not address the underlying issue effectively.

Question 2 of 5

The nurse-manager of a skilled nursing (chronic care) unit is instructing UAPs on ways to prevent complications of immobility. Which intervention should be included in this instruction?

Correct Answer: A

Rationale: Performing range-of-motion exercises is essential in preventing contractures, which are common complications of immobility. These exercises help maintain joint flexibility and muscle strength, reducing the risk of contractures that can lead to functional limitations or pain for the client. Choices B, C, and D are incorrect. Decreasing fluid intake does not prevent immobility complications, but it can lead to dehydration. Massaging the client's legs does not directly address the prevention of immobility complications like contractures. Turning the client from side to back every shift is important for preventing pressure ulcers but does not directly address complications of immobility like contractures.

Question 3 of 5

A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?

Correct Answer: A

Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.

Question 4 of 5

A client with a diagnosis of asthma is receiving albuterol (Proventil) via a metered-dose inhaler (MDI). Which assessment finding indicates that the medication is effective?

Correct Answer: A

Rationale: Increased oxygen saturation (A) is the most direct indicator of the effectiveness of albuterol (Proventil) in improving breathing. Oxygen saturation reflects the amount of oxygen in the blood, showing that the albuterol is helping with air exchange in the lungs. While decreased respiratory rate (B), absence of audible wheezing (C), and improved exercise tolerance (D) are positive outcomes, they are secondary to oxygen saturation. Oxygen saturation directly reflects the improvement in the client's respiratory status and the effectiveness of the medication.

Question 5 of 5

The nurse is providing discharge teaching to a client with a new diagnosis of osteoporosis. Which instruction should the nurse include?

Correct Answer: B

Rationale: Avoiding activities that increase the risk of falls (B) is the most crucial instruction for a client with osteoporosis to prevent fractures. Osteoporosis weakens bones, making them more susceptible to fractures from falls. While increasing calcium intake (A) is important for bone health, avoiding falls takes precedence to prevent immediate harm. Avoiding prolonged exposure to sunlight (C) is not directly related to osteoporosis management. Increasing vitamin D supplements (D) is beneficial for bone health, but fall prevention is more critical in this scenario.

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