HESI Fundamentals Exam Test Bank

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While suctioning a client's nasopharynx, the nurse observes that the client's oxygen saturation remains at 94%, which is the same reading obtained prior to starting the procedure. What action should the nurse take in response to this finding?

  • A. Complete the intermittent suction of the nasopharynx.
  • B. Reposition the pulse oximeter clip to obtain a new reading.
  • C. Stop suctioning until the pulse oximeter reading is above 95%.
  • D. Apply an oxygen mask over the client's nose and mouth.
Correct Answer: A

Rationale: The correct action for the nurse to take in this situation is to complete the intermittent suction of the nasopharynx. Since the oxygen saturation remains stable at 94%, which was the initial reading, it indicates that the procedure is not causing a significant drop in oxygen levels. Stopping the suctioning or applying oxygen may not be necessary as the saturation level is within an acceptable range. Repositioning the pulse oximeter clip is unlikely to change the reading significantly. Therefore, completing the procedure maintains care consistency and effectiveness, ensuring proper airway management without unnecessary interventions. Choices B, C, and D are incorrect because repositioning the pulse oximeter clip, stopping suctioning until a higher reading is achieved, and applying oxygen are not warranted based on the stable oxygen saturation level of 94% throughout the procedure.

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While auscultating the anterior chest of a client newly admitted to a medical-surgical unit, a nurse listens to the audio clip of breath sounds through her stethoscope. What type of breath sounds does the nurse hear?

  • A. Crackles
  • B. Rhonchi
  • C. Friction rub
  • D. Normal breath sounds
Correct Answer: D

Rationale: The correct answer is D: Normal breath sounds. In the scenario described, the nurse hears normal bronchovesicular breath sounds, which are moderate in intensity and resemble blowing as air moves through the larger airways during inspiration and expiration. Crackles (choice A) are typically heard in conditions like heart failure or pneumonia and are not present in this case. Rhonchi (choice B) are low-pitched, continuous sounds often associated with conditions like chronic bronchitis or bronchiectasis. Friction rub (choice C) is a grating sound usually heard in conditions like pleurisy or pericarditis, which is not the case here where normal breath sounds are heard.

To use the nursing process correctly, what must the nurse do first?

  • A. Obtain information about the client
  • B. Develop a care plan
  • C. Implement interventions
  • D. Evaluate the client's outcomes
Correct Answer: A

Rationale: The first step in the nursing process is to obtain information about the client. This step involves gathering data through assessment to understand the client's needs, health status, and preferences. Developing a care plan (Choice B) comes after the assessment phase. Implementing interventions (Choice C) and evaluating client outcomes (Choice D) occur in subsequent stages of the nursing process. Therefore, the correct initial step is to gather information about the client to form a foundation for providing individualized care.

What should be done when caring for a client who died?

  • A. Obtain orders, Remove tubes, Wash client, Ask family, Place tags.
  • B. Wash client, Obtain orders, Place tags, Remove tubes, Ask family.
  • C. Remove tubes, Obtain orders, Ask family, Place tags, Wash client.
  • D. Ask family, Place tags, Wash client, Remove tubes, Obtain orders.
Correct Answer: A

Rationale: When caring for a deceased client, the correct sequence of actions involves first obtaining any necessary orders, then removing tubes, washing the client, asking the family for specific requests, and finally placing identification tags. This order ensures proper care and respect for the deceased individual. Option A presents the correct order of actions. Choice B is incorrect because washing the client should be done after removing tubes. Choice C is incorrect as it does not follow the correct order of actions. Choice D is incorrect because asking the family should be done after caring for the client's body, not before.

The healthcare provider is assessing a client with a diagnosis of asthma. Which assessment finding would be most concerning?

  • A. Wheezing
  • B. Shortness of breath
  • C. Use of accessory muscles
  • D. Cough with sputum production
Correct Answer: C

Rationale: The most concerning assessment finding in a client with asthma is the use of accessory muscles. This indicates that the client is working harder to breathe, which could signify respiratory distress. Wheezing, choice A, is a common finding in asthma and indicates narrowed airways but may not necessarily imply immediate distress. Shortness of breath, choice B, is also common in asthma but may not be as concerning as the use of accessory muscles. Cough with sputum production, choice D, can occur in asthma exacerbations but may not be as critical as signs of increased work of breathing like the use of accessory muscles.

When preparing an injection for opioid medication, a nurse draws 1mL from a 2mL vial. What should the nurse do next?

  • A. Ask another nurse to observe medication wastage
  • B. Document the amount of medication drawn on the MAR
  • C. Dispose of the remaining medication in a sharps container
  • D. Administer the entire vial of medication to avoid wastage
Correct Answer: A

Rationale: When drawing medication from a vial, especially for controlled substances like opioids, any wastage must be witnessed by another healthcare professional to ensure accuracy, prevent diversion, and maintain safety standards. This process is crucial for proper documentation and accountability. Recording the amount drawn on the Medication Administration Record (MAR) is important for tracking administered doses and preventing errors. Disposing of the remaining medication in a sharps container is not recommended as it does not address proper wastage documentation. Administering the entire vial of medication just to avoid wastage is inappropriate and can lead to potential harm or overdose in the patient.

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