HESI RN
HESI Fundamentals Practice Exam Questions
Question 1 of 5
In a client with moderate, persistent, chronic neuropathic pain due to diabetic neuropathy who takes gabapentin (Neurontin) and ibuprofen (Motrin, Advil) daily, if Step 2 of the World Health Organization (WHO) pain relief ladder is prescribed, which drug protocol should be implemented?
Correct Answer: A
Rationale: In the presence of moderate, persistent, chronic neuropathic pain, the WHO pain relief ladder recommends continuing gabapentin, as it is effective for managing both anxiety and pain. Ibuprofen, a nonsteroidal anti-inflammatory drug, is not the mainstay for neuropathic pain relief according to the ladder and can be discontinued if needed. Aspirin is not typically added to the protocol for neuropathic pain management at this step. Methadone is reserved for severe pain and is not the standard choice at Step 2 of the WHO pain relief ladder for neuropathic pain.
Question 2 of 5
Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
Correct Answer: A
Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.
Question 3 of 5
A client is admitted with a diagnosis of fluid volume deficit. Which clinical finding would the nurse expect?
Correct Answer: D
Rationale: Dry mucous membranes (D) are a common clinical finding indicating fluid volume deficit. In dehydration, there is insufficient fluid in the body, leading to dry mucous membranes due to decreased saliva production. Bounding pulse (A) is associated with fluid volume excess, not deficit. Bradycardia (B) and oliguria (C) are not typical clinical findings of fluid volume deficit but may be seen in fluid volume excess or other conditions.
Question 4 of 5
A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?
Correct Answer: D
Rationale: Restricting dietary sodium intake (D) is the most critical intervention for a client with fluid volume excess to prevent further fluid retention. Encouraging increased fluid intake (A) would exacerbate the issue by adding more fluid to the body. Placing the client in a high Fowler's position (B) is more relevant for respiratory issues than fluid volume excess. While measuring intake and output (C) is important for assessing fluid balance, restricting sodium intake is the priority as it helps manage fluid levels more effectively by reducing fluid retention.
Question 5 of 5
What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?
Correct Answer: D
Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the client's room. This precaution is essential to prevent the spread of MRSA and protect both the client and the healthcare worker from potential infection. Choice A is incorrect because visitors should not be restricted solely based on contact precautions. Choice B is incorrect as wearing sterile gloves is not necessary, standard precautions with regular gloves are sufficient. Choice C is incorrect because the client wearing a mask is not a standard practice for contact precautions; it is the healthcare worker who should take preventive measures.
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