HESI Fundamentals Practice Exam

Questions 53

HESI RN

HESI RN Test Bank

HESI Fundamentals Practice Exam Questions

Question 1 of 5

The UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?

Correct Answer: A

Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.

Question 2 of 5

A client with a diagnosis of hyperkalemia is receiving sodium polystyrene sulfonate (Kayexalate). Which laboratory value should the nurse monitor to evaluate the effectiveness of this medication?

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.

Question 3 of 5

The client is weak from inactivity due to a 2-week hospitalization. In planning care for the client, which range of motion (ROM) exercises should the nurse include?

Correct Answer: B

Rationale: Active ROM exercises are preferred over passive ROM to restore strength. Performing them on both arms and legs two or three times a day is effective in promoting muscle strength and mobility without the need for external assistance. Choice A is incorrect as passive ROM exercises may not help in restoring strength. Choice C is not recommended as using weights may be too strenuous for a weak client. Choice D is incorrect as passive ROM exercises to the point of resistance and slightly beyond may cause discomfort or injury to the weak client.

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

Which assessment data would provide the most accurate determination of proper placement of a nasogastric tube?

Correct Answer: C

Rationale: The most accurate method to confirm the proper placement of a nasogastric tube is by examining a chest x-ray obtained after the tubing was inserted. This visual assessment allows healthcare providers to directly visualize the position of the tube in relation to anatomical landmarks, ensuring it is correctly placed in the stomach. Aspirating gastric contents or hearing air pass may provide some information but are not as definitive as a chest x-ray for confirming placement. Checking the remaining length of tubing is not a reliable method for determining proper placement as it does not indicate where the tip of the tube lies within the body.

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