HESI Fundamentals Practice Questions

HESI Fundamentals Practice Questions Related

Review HESI Fundamentals Practice Questions related questions and content

A client who is unstable and requires frequent vital signs has an electronic blood pressure machine automatically measuring his blood pressure every 15 min. However, the machine is reading the client's blood pressure at more frequent intervals, and the readings are not similar. The nurse checks the machine settings and observes the additional readings, but the problem continues. Which of the following is the appropriate nursing action?

  • A. Notify the manufacturer
  • B. Disconnect the machine, and measure the blood pressure manually every 15 min
  • C. Adjust the machine settings again
  • D. Ignore the extra readings
Correct Answer: B

Rationale: The correct action in this scenario is to disconnect the electronic blood pressure machine and measure the client's blood pressure manually every 15 minutes. Given that the machine is malfunctioning and providing inconsistent readings, relying on manual measurements ensures accuracy and maintains the quality of care. Notifying the manufacturer (Choice A) may be necessary in the long run, but the immediate concern is the accuracy of the vital signs. Adjusting the machine settings again (Choice C) without resolving the underlying issue would not address the problem. Ignoring the extra readings (Choice D) could lead to incorrect assessment and compromise patient care. Therefore, the best course of action is to disconnect the machine and opt for manual blood pressure measurements until the issue is resolved.

You may also like to solve these questions

A client with lower extremity weakness is being taught a four-point crutch gait by a nurse. Which of the following instructions should the nurse include in the teaching?

  • A. Bear weight on both legs.
  • B. Move the crutches and the weak leg in unison.
  • C. Advance the crutches and the strong leg simultaneously.
  • D. Move the crutches forward, then move one leg at a time.
Correct Answer: D

Rationale: The correct technique for a four-point crutch gait involves moving the crutches forward, then moving one leg at a time. This method provides stability and support by alternating movement between the crutches and legs. Choice A is incorrect because bearing weight on both legs simultaneously is not the correct method for a four-point gait. Choice B is incorrect as moving the crutches and weak leg together does not provide the required stability. Choice C is incorrect as advancing the crutches and strong leg together does not promote the alternating movement needed for a four-point gait.

Which action is most important for maintaining sterility when donning sterile gloves?

  • A. Maintain thumbs at a ninety-degree angle.
  • B. Hold hands with fingers pointing downward while gloving.
  • C. Keep gloved hands above the elbows.
  • D. Put the glove on the dominant hand first.
Correct Answer: C

Rationale: The most crucial action for maintaining sterility when donning sterile gloves is to keep gloved hands above the elbows. This practice is essential to prevent potential contamination and maintain a sterile field. Choices A, maintaining thumbs at a ninety-degree angle, and B, holding hands with fingers pointing downward while gloving, are not as critical as keeping hands above the elbows for maintaining sterility. Choice D, putting the glove on the dominant hand first, is not as important as ensuring that gloved hands are kept above the elbows to maintain sterility.

A parent asks a nurse about his infant's expected physical development during the first year of life. Which of the following information should the nurse include?

  • A. A 10-month-old infant can pull up to a standing position.
  • B. A 6-month-old infant can walk with assistance.
  • C. A 12-month-old infant can jump with both feet.
  • D. An 8-month-old infant can crawl on hands and knees.
Correct Answer: A

Rationale: The correct answer is A. By 10 months, infants can typically pull up to a standing position as part of their physical development. Walking with assistance usually begins around 9-12 months, not at 6 months (choice B). Jumping with both feet is a skill that usually develops around 24 months, not at 12 months (choice C). Crawling on hands and knees typically starts around 6-9 months, not at 8 months (choice D). Therefore, the most accurate information to include for an infant's expected physical development at 10 months is the ability to pull up to a standing position.

A patient has been diagnosed with osteoporosis and lactose intolerance. What intervention will the nurse implement?

  • A. Encourage dairy alternatives.
  • B. Monitor intake of vitamin D.
  • C. Increase intake of caffeinated drinks.
  • D. Assist the patient with daily activities.
Correct Answer: B

Rationale: The correct intervention for a patient diagnosed with osteoporosis and lactose intolerance is to monitor their intake of vitamin D. Since the patient has lactose intolerance, encouraging dairy alternatives (Choice A) would not be appropriate. Increasing intake of caffeinated drinks (Choice C) is not beneficial for managing osteoporosis and may even have negative effects on bone health. Assisting the patient with daily activities (Choice D) is a general nursing intervention that may not directly address the specific needs related to osteoporosis and lactose intolerance.

A client with a history of falls is under the care of a nurse. Which of the following actions should the nurse take to prevent falls?

  • A. Keep the client's bed in the lowest position.
  • B. Encourage the client to wear non-slip socks.
  • C. Place a fall risk sign on the client's door.
  • D. Use a gait belt when ambulating the client.
Correct Answer: A

Rationale: Keeping the client's bed in the lowest position is an essential measure to prevent falls. Lowering the bed reduces the risk of injury if the client falls out of bed by decreasing the distance of the fall. Encouraging the client to wear non-slip socks (Choice B) may help prevent slips on smooth surfaces but does not address the risk of falls in other scenarios. Placing a fall risk sign on the client's door (Choice C) alone does not actively prevent falls but serves as a warning. Using a gait belt when ambulating the client (Choice D) is important for assisting with mobility but does not directly address fall prevention in the client's environment.

Copyright © 2025 Nokea. All rights reserved.