HESI RN Fundamentals Exam

HESI RN Fundamentals Exam

VERSION 7

• A nurse is caring for a client who has left lower atelectasis. in which of the following positions should the nurse

place the client for postural drainage?

• Supine and low-Fowler's position
• Right lateral in Trendelenburg position
• Side lying with the right side of the chest elevated
• Prone with pillows under the extremities

• A nurse is caring for a client who is scheduled to have his alanine aminotransferase (ALT) level checked. The

client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?

• “This test will indicate if you are at risk for developing blood clots
• “This test will determine if your heart is performing properly”
• “This test will provide information about the function of your liver”

 Rationale: ALT test measures amount of enzyme in blood. ALT mainly found in liver  Rationale: Leadership 7.0. ALT and AST measure you liver function. Creatinine and BUN measure your kidney function

• “This test is used to check how your kidneys are working”

.

• A nurse is caring for a client who has a prescription for morphine 5mg IM accidentally administers the whole 10

mg from the single-dose vial. Which of the following actions should the nurse take first?

• Notify the client‟s provider.
• Report the incident to the pharmacy.
• Complete an incident report.
• Measure the client’s respiratory rate.

 Rationale: morphine OD = pulmonary edema  fills lungs w/ fluid  leading cause of death for OD  Rationale: Morphine can cause respiratory depression if given too much. Also you should ALWAYS ASSESS the patient first when a med error is performed to make sure med error doesn‟t put the client‟s health in risk. 1 / 3

• A nurse is preparing to administer diphenhydramine 20 mg orally to a 6-year-old child who has difficulty

swallowing pills. Available is diphenhydramine 12.5 mg/5 mL oral syrup. Which of the following images shows the correct # of mL the nurse should administer? (Round the answer to the nearest whole number.) Click on the syringe that has 8 mL of med.20 mg x (5mL/12.5mg) = 8 mL

• A nurse is caring for a 6-year-old child who has a new prescription for cefoxitin 80 mg/kg/day administered

intravenously every 6 hour. The child weighs 20 kg. How much cefoxitin should the nurse administer with each dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)  So it says each dose for the final answer, but we are given 80 mg/kg/day. 80 x 20 = 1600 / 4 (dose is given every 6 hours a day) =400 mg

 Rationale: 80 mg x 20 kg = 1,600  1,600/4 x day (q6h) = 400 mg

• A nurse is preparing to administer IV fluids to a client. The nurse notes sparks when plugging in the IV pump.

Which of the following actions should the nurse take first?

• Label the pump with a defective equipment sticker.
• Unplug the pump.
• Obtain a replacement pump.
• Notified the biomedical department to fix the pump.

 Rationale: Prioritization question. YOU WILL FIRST UNPLUG the IV pump to avoid causing a fire.

• A nurse is caring for a client who has a surgical wound. Which of the following laboratory values places the client

at risk for poor wound healing?

• Serum albumin 3 g/dL
• Total lymphocyte count 2400 mm3
• HCT 42%
• HGB 16g/dL

 Rationale: Albumin in low. Normal range is 3.5 to 5.5 g/dL. Low albumin places the client at risk forpoor wound healing. The other lab values are within normal limits.

• A nurse is preparing to check a client's blood pressure. Which of the following actions should the nurse take?

Chapter 27 Vitals signs page 244

• Apply the cuff above the client‟s antecubital fossa.
• Use a cuff with a width that is about 60% of the client's arm circumference. - width of the cuff should be 40 %

of arm circumference

• How the clients sit with his arm resting above the level of his heart. - MUST BE AT HEART LEVEL 2 / 3

• Release the pressure on the client's arm 5 to 6 mm per second. - pressure release should not be more than 2 to
• mm hg per second

 Rationale: ATI FUNDA says 40% of the arm circumference pg. 139. Release the pressure no faster than 2 to

• mm Hg per second. Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in

line with the marking on the cuff.Apply the BP cuff 2.5 cm (1 in) above the antecubital space with the brachial artery in line with the marking on the cuff.

• A nurse is preparing to perform nasal tracheal suctioning for a client. Which of the following is an appropriate

action for the nurse to take? Chapter 53 Airway management page 563

• Hold the suction catheter with the clean non-dominant hand.
• Apply suctioning for 20 to 30 seconds.- 10 -15 seconds is the maximum.
• Place the catheter in a location that is clean and dry for later use new line.- NEVER EVER REUSE THE

SUCTION CATHETER . you throw it away after being used.

• Use surgical asepsis when performing the procedure.- book say medical asepsis which is maybe the

same thing .

 Rationale: sterile technique for trachea

 Rationale: ATI FUNDA. PG. 316 Use surgical asepsis for all types of suctioning. No longer than 10-15 seconds to avoid hypoxemia

• A nurse is documenting client care. Which of the following abbreviations should the nurse use?ati book was not

thorough so i had to go on different sites for charts - not confident with this, please double check.

• “SS” for sliding scale
• “BRP” for bathroom privileges
• “OJ” for orange juice- do not
• “SQ” for subcutaneous- do not

11. MISSING

• A nurse is collecting A blood pressure reading from a client who is sitting in a chair period the nurse determines

that the clients BP is 158/96 mmhg. which of the following actions should the nurse take?

• Ensure that the width of the BP cuff is 50% of the client‟s upper arm circumference. It says 40%
• Reposition the client Supine and recheck her BP. BP. → ORTHOSTATIC HYPOTENSION
• Recheck the clients BP and her other arm for comparison.
• Request that another nurse check the the clients BP in 30 minutes. → 15 minutes
• / 3