HESI Fundamentals Exam

HESI Fundamentals Exam Related

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A client has undergone an allogeneic stem cell transplant, and a nurse is initiating a protective environment. Which precaution should the nurse plan for this client?

  • A. Ensure the client wears a mask when outside the room if there is construction in the area.
  • B. Place the client in a room with other immunocompromised patients.
  • C. Allow the client to visit public areas freely.
  • D. Ensure the client does not need any special precautions.
Correct Answer: A

Rationale: For a client who has undergone an allogeneic stem cell transplant, it is crucial to maintain a protective environment to prevent infections. Wearing a mask when outside the room, especially if there is construction in the area, helps reduce the risk of exposure to harmful pathogens. This precaution is essential as the client's immune system is compromised post-transplant. Placing the client in a room with other immunocompromised patients (choice B) would increase the risk of infections as it exposes the client to a higher pathogen load. Allowing the client to visit public areas freely (choice C) is not recommended due to the higher risk of exposure to infections. Ensuring the client does not need any special precautions (choice D) is incorrect because clients post allogeneic stem cell transplant require protective measures to prevent complications.

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During preoperative teaching, a client in a surgeon's office expresses intent to prepare advance directives before surgery. Which statement by the client indicates understanding of advance directives?

  • A. "I'd prefer my brother to make decisions, but I understand it must be my wife."
  • B. "I understand the surgery won't proceed unless I fill out these forms."
  • C. "I plan to specify my wish to avoid being kept on a breathing machine."
  • D. "I will have my primary doctor review my plan before submitting it at the hospital."
Correct Answer: C

Rationale: The correct answer is C. This statement reflects the client's understanding of advance directives, as it indicates a specific preference regarding life-sustaining treatment. Advance directives enable individuals to outline their healthcare preferences, including decisions about treatments they wish to receive or avoid. Choice A mentions family members but doesn't address specific healthcare wishes; choice B focuses on the surgery rather than personal directives; choice D discusses doctor approval but lacks details about the directive itself.

While bathing a patient, the nurse notices movement in the patient's hair. What action should the nurse take?

  • A. Use gloves to inspect the hair.
  • B. Apply a lindane-based shampoo immediately.
  • C. Shave the patient's hair off.
  • D. Ignore the movement and continue.
Correct Answer: A

Rationale: When a nurse suspects pediculosis capitis (head lice) upon noticing movement in the patient's hair, the correct action is to use gloves to inspect the hair. This protects the nurse from potential self-infestations. Applying a lindane-based shampoo immediately (Choice B) is not the first action, as diagnosis and confirmation are necessary before treatment. Shaving the patient's hair off (Choice C) is an extreme measure and is unnecessary at this stage. Ignoring the movement and continuing (Choice D) is negligent and can lead to the spread of infestation.

A client reports mild back pain after receiving analgesia 1 hour ago. Which non-pharmacological pain method should the nurse plan to use?

  • A. Apply an ice pack to the client's back for 1 hour.
  • B. Remove distractions from the client's room.
  • C. Instruct the client to take deep rhythmic breaths.
  • D. Encourage the client to apply a heating pad for 2 hours at a time.
Correct Answer: C

Rationale: In this scenario, the nurse should instruct the client to take deep rhythmic breaths as a non-pharmacological pain management method. Deep breathing can help the client relax, reduce stress, and manage pain effectively. Applying heat or ice for prolonged periods can lead to tissue damage. Removing distractions can be helpful for promoting relaxation but may not directly address the pain itself.

A client is admitted with a diagnosis of Guillain-Barre syndrome. Which assessment finding is most concerning?

  • A. Loss of reflexes in the legs
  • B. Decreased peripheral sensation
  • C. Respiratory distress
  • D. Muscle weakness in the arms
Correct Answer: C

Rationale: The correct answer is C: Respiratory distress. In Guillain-Barre syndrome, respiratory distress is the most concerning finding as it can indicate progression to respiratory failure, which is a life-threatening complication. Loss of reflexes in the legs and muscle weakness in the arms are common manifestations of the condition but may not be as immediately life-threatening as respiratory distress. Decreased peripheral sensation is also a common symptom but is not as critical as respiratory distress in terms of immediate patient safety and management.

The nurse is working on an orthopedic rehabilitation unit that requires lifting and positioning of patients. Which personal injury will the nurse most likely try to prevent?

  • A. Arm
  • B. Hip
  • C. Back
  • D. Ankle
Correct Answer: C

Rationale: The correct answer is C: Back. Back injuries are common among healthcare workers, especially nurses, due to improper lifting techniques and bending. Working on an orthopedic rehabilitation unit involves frequent lifting and positioning of patients, putting the nurse at risk of back injuries. Preventing back injuries is crucial for maintaining the nurse's health and ability to provide care effectively. Choices A, B, and D are incorrect because while lifting and positioning patients may involve these body parts, back injuries are most likely to occur due to the strain and stress placed on the back during such activities.

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