HESI Fundamentals Practice Exam

HESI Fundamentals Practice Exam Related

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When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?

  • A. Self-care deficit
  • B. Functional incontinence
  • C. Fluid volume deficit
  • D. High risk for infection
Correct Answer: D

Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections.

Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.

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An older female client with rheumatoid arthritis is complaining of severe joint pain that is caused by the weight of the linen on her legs. What action should the nurse implement first?

  • A. Apply flannel pajamas to provide warmth.
  • B. Administer a PRN dose of ibuprofen.
  • C. Perform range of motion exercises in a warm tub.
  • D. Drape the sheets over the footboard of the bed.
Correct Answer: D

Rationale: The correct answer is D. The nurse should first address the immediate comfort concern of the client, which is the weight of the linen on her legs causing severe joint pain. By draping the sheets over the footboard of the bed rather than tucking them under the mattress, the nurse can alleviate the pressure that the client perceives as the source of her pain. This action is a simple and effective way to provide relief and should be the initial step taken by the nurse. Choices A, B, and C do not directly address the client's immediate discomfort caused by the weight of the linen on her legs, making them less appropriate initial actions.

A healthcare professional is working in an occupational health clinic when an employee walks in and states that he was struck by lightning while working in a truck. The client is alert but reports feeling faint. Which assessment will the healthcare professional perform first?

  • A. Pulse characteristics
  • B. Open airway
  • C. Entrance and exit wounds
  • D. Cervical spine injury
Correct Answer: A

Rationale: When a person is struck by lightning, it can cause an electrical shock that may affect the heart rhythm. Therefore, assessing pulse characteristics is crucial as lightning can act as a natural defibrillator. Monitoring the pulse rate and regularity will help determine if there are any cardiac abnormalities that need immediate attention. Open airway, entrance and exit wounds, and cervical spine injury assessments are also important but assessing pulse characteristics takes precedence in this situation to address potential cardiac issues.

The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?

  • A. Administer nasal oxygen at a rate of 5 L/min
  • B. Help the client to lie back down in the bed
  • C. Quickly pivot the client to the chair and elevate the legs
  • D. Check the client's blood pressure and pulse
Correct Answer: D

Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.

A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which intervention should the nurse implement first?

  • A. Administer sublingual nitroglycerin
  • B. Obtain a 12-lead electrocardiogram (ECG)
  • C. Apply oxygen via nasal cannula
  • D. Initiate continuous cardiac monitoring
Correct Answer: C

Rationale: In a client with a history of coronary artery disease (CAD) experiencing chest pain, the priority intervention for the nurse to implement first is to apply oxygen via nasal cannula. Oxygenation is crucial to ensure adequate oxygen supply to the tissues and the heart. This intervention takes precedence over administering sublingual nitroglycerin, obtaining an ECG, or initiating continuous cardiac monitoring. While these interventions are important, ensuring adequate oxygenation is the initial priority in the management of a client with chest pain.

A client is admitted with a diagnosis of fluid volume excess. Which intervention should the nurse include in the client's plan of care?

  • A. Encourage increased fluid intake.
  • B. Place the client in a high Fowler's position.
  • C. Measure the client's intake and output.
  • D. Restrict dietary sodium intake.
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.

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