HESI RN
HESI Fundamentals Practice Test Questions
Question 1 of 5
The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?
Correct Answer: A
Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.
Question 2 of 5
A client has a nursing diagnosis of 'spiritual distress.' What intervention is best for the nurse to implement when caring for this client?
Correct Answer: D
Rationale: When a client is going through spiritual distress, employing reflective listening techniques is crucial. This method allows the client to voice their concerns and emotions, providing them with a supportive environment to explore their feelings. Options A and B do not directly address the client's spiritual distress and may undermine the client's feelings. While option C involves a chaplain, using reflective listening directly involves the nurse in addressing and supporting the client's spiritual concerns.
Question 3 of 5
When assessing for orthostatic hypotension during blood pressure measurement, what action should the nurse implement first?
Correct Answer: A
Rationale: When assessing for orthostatic hypotension, the initial step is to position the client supine for a few minutes. This allows the body to adjust to the supine position before assessing blood pressure changes that may indicate orthostatic hypotension. By observing the blood pressure after the client has rested supine, the nurse can accurately assess for any drop in blood pressure upon standing, which is indicative of orthostatic hypotension. Choices B, C, and D are incorrect as they do not address the initial step in assessing for orthostatic hypotension, which is ensuring the client is positioned correctly to detect blood pressure changes upon standing.
Question 4 of 5
The client with chronic obstructive pulmonary disease (COPD) is receiving oxygen therapy. Which intervention should the nurse implement to ensure the client's safety?
Correct Answer: B
Rationale: Monitoring the client's respiratory rate and effort is essential to evaluate the effectiveness of oxygen therapy and prevent complications such as respiratory depression. This intervention helps the nurse promptly detect any deterioration in the client's respiratory status and take necessary actions to ensure the client's safety. Encouraging continuous oxygen use (Choice A) may lead to oxygen toxicity. Setting the oxygen flow rate at a specific level (Choice C) without individual assessment can be inappropriate and potentially harmful. Teaching the client to avoid wearing wool blankets (Choice D) is unrelated to the safe use of oxygen therapy.
Question 5 of 5
Why is it most important to start intravenous infusions in the upper extremities rather than the lower extremities of adults?
Correct Answer: B
Rationale: The most critical reason for initiating intravenous infusions in the upper extremities of adults is to reduce the risk of thrombosis (B). Venous return is typically better in the upper extremities, decreasing the likelihood of thrombus formation, which could be life-threatening if dislodged. Although superficial veins are easily found in the feet and ankles (A), this is not the primary reason for choosing the upper extremities. Handling a leg or foot with an IV (C) is not significantly more challenging than handling an arm or hand. The depth of veins in the feet and ankles (D) does not primarily determine the site for IV placement.
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