HESI Fundamentals Practice Questions

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A client with a tracheostomy is being taught by a nurse and their family how to care for the tracheostomy at home. Which of the following should the nurse include in the teaching?

  • A. Use tracheostomy covers when outdoors.
  • B. Clean the tracheostomy with alcohol.
  • C. Replace the tracheostomy tube every week.
  • D. Cover the tracheostomy with a wet cloth when sleeping.
Correct Answer: A

Rationale: Using tracheostomy covers when outdoors is essential to protect the tracheostomy from dust and debris, reducing the risk of infection. Tracheostomy covers help maintain cleanliness and prevent foreign particles from entering the stoma. Choice B is incorrect because cleaning the tracheostomy with alcohol can be too harsh and drying for the skin surrounding the stoma, leading to skin irritation. Choice C is incorrect as tracheostomy tubes are typically replaced only when clinically indicated or as per the healthcare provider's instructions, not routinely every week, to prevent unnecessary risks and complications. Choice D is incorrect as covering the tracheostomy with a wet cloth when sleeping can create a moist environment ideal for bacterial growth, increasing the risk of infection and skin breakdown. It is important to keep the tracheostomy site clean, dry, and protected to maintain optimal hygiene and prevent complications.

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A nurse is caring for a client receiving fluid through a peripheral IV catheter. Which of the following findings at the IV site should the nurse identify as infiltration?

  • A. purulent exudate
  • B. warmth
  • C. skin blanching
  • D. bleeding
Correct Answer: C

Rationale: Infiltration occurs when the IV fluid leaks into the surrounding tissue instead of entering the bloodstream properly. Skin blanching, swelling, and coolness at the IV site are typical signs of infiltration. Purulent exudate (choice A) is associated with infection, warmth (choice B) can indicate phlebitis, and bleeding (choice D) may occur if the IV catheter punctures a blood vessel.

A cerebrovascular accident patient is placed on a ventilator. The client's daughter arrives with a durable power of attorney and a living will that indicates no extraordinary life-saving measures. What action should the nurse take?

  • A. Refer to the risk manager
  • B. Notify the healthcare provider
  • C. Discontinue the ventilator
  • D. Review the medical record
Correct Answer: B

Rationale: The correct action for the nurse to take is to notify the healthcare provider. In this situation, involving the healthcare provider ensures appropriate review and adherence to legal and ethical standards based on the living will and durable power of attorney. Referring to the risk manager may not be directly related to the immediate decision-making process regarding the ventilator. Discontinuing the ventilator without proper authorization from the healthcare provider could lead to legal and ethical implications. Reviewing the medical record alone may not provide guidance on how to proceed with the specific instructions from the living will and durable power of attorney.

When assessing the respiratory system for complications of immobility, what action should the nurse take?

  • A. Inspect chest wall movements primarily during the expiratory cycle.
  • B. Auscultate the entire lung region to assess lung sounds.
  • C. Focus auscultation on the upper lung fields.
  • D. Assess the patient at least every 4 hours.
Correct Answer: B

Rationale: The correct action for the nurse when assessing the respiratory system for complications of immobility is to auscultate the entire lung region. This approach allows the nurse to identify any diminished breath sounds, crackles, or wheezes that may indicate respiratory issues. Inspecting chest wall movements primarily during the expiratory cycle (Choice A) may not provide a comprehensive assessment of lung sounds. Focusing auscultation on the upper lung fields (Choice C) may miss important findings in the lower lung fields. Assessing the patient at least every 4 hours (Choice D) is important for monitoring overall patient condition but does not specifically address the assessment of respiratory complications related to immobility.

When is a depressed client at highest risk for attempting suicide?

  • A. Immediately after admission, during one-to-one observation
  • B. 7 to 14 days after initiation of antidepressant medication and psychotherapy
  • C. Following an angry outburst with family
  • D. When the client is removed from the security room
Correct Answer: B

Rationale: Depressed clients are at the highest risk of attempting suicide 7 to 14 days after starting antidepressant medication and psychotherapy. During this time, they may start to regain energy but still feel hopeless, which can increase the risk of suicidal ideation and behavior. Choices A, C, and D are incorrect because immediate post-admission, after an angry outburst with family, or when removed from a security room are not specific periods known to be associated with the highest risk of suicide in depressed clients.

A client is reporting difficulty falling asleep. Which of the following measures should the nurse recommend?

  • A. Drink a cup of hot cocoa before bedtime
  • B. Exercise 1 hour before going to bed
  • C. Use progressive relaxation techniques at bedtime
  • D. Reflect on the day's activities before going to bed
Correct Answer: C

Rationale: The correct answer is to recommend the client to use progressive relaxation techniques at bedtime. Progressive relaxation techniques help reduce stress and muscle tension, which can promote better sleep. Choice A, drinking a cup of hot cocoa before bedtime, contains caffeine which can interfere with falling asleep. Choice B, exercising 1 hour before going to bed, can stimulate the body and mind, making it harder to fall asleep. Choice D, reflecting on the day's activities before going to bed, may lead to increased mental activity and prevent relaxation, making it difficult to fall asleep.

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