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HESI RN Fundamentals Exam 1
Total Questions : 55
Showing 10 questions, Sign in for moreThe client is an 81-year-old male with a history of hypertension, heart failure, and seasonal allergies. He was admitted for pneumonia 3 days ago and is currently in the intensive care unit. The client lives with his daughter and her family, who report that he is compliant with his medication regimen. The client walks every morning but has shown cognitive decline at home and has no signs of improvement. The client has been experiencing increased confusion, lethargy, and decreased appetite. He has also developed a persistent cough with greenish sputum and shortness of breath.
- Hypertension
- Heart failure
- Seasonal allergies
- Pneumonia (admitted 3 days ago)
- White Blood Cell (WBC) count: 15,000/mm³ (4,500-11,000/mm³)
- C-reactive protein (CRP): 12 mg/L (<3 mg/L)
- Blood urea nitrogen (BUN): 25 mg/dL (7-20 mg/dL)
- Serum creatinine: 1.5 mg/dL (0.6-1.2 mg/dL)
- Chest X-ray: Bilateral infiltrates
- Temperature: 38.5°C (101.3°F)
- Heart rate: 110 beats per minute
- Respiratory rate: 28 breaths per minute
- Blood pressure: 140/90 mmHg
- Oxygen saturation: 88% on room air
- Administer IV antibiotics as prescribed
- Administer oxygen therapy to maintain SpO2 > 92%
- Monitor vital signs every 4 hours
- Encourage fluid intake
- Perform chest physiotherapy
The client appears pale and diaphoretic. He has bilateral crackles in the lower lung fields and diminished breath sounds. The client is using accessory muscles to breathe and has a productive cough with greenish sputum. His skin is warm to the touch, and he has mild peripheral edema in the lower extremities. The client is alert but disoriented to time and place.
A nurse is caring for a client in the intensive care unit.
Complete the diagram by specifying which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client’s progress.
Explanation
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Most Likely Condition: The client is most likely experiencing Hospital-acquired pneumonia ©. This is indicated by the recent admission for pneumonia, persistent cough with greenish sputum, increased WBC count, and bilateral infiltrates on the chest X-ray. Actions to Take: |
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Parameters to Monitor:
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The nurse is caring for a client who is postoperative and receiving supplemental oxygen at 2 L/minute via nasal cannula. The oxygen saturation is 89%. Which action should the nurse implement?
The nurse is caring for a client with type 2 diabetes mellitus who had surgery for a large bowel resection with a colostomy placement.
The client has now developed hyperglycemia which requires self-injections of insulin after discharge. When designing the postoperative plan of care, which outcome statement should the nurse use?
When assessing a client with a serum potassium level of 7.5 mEq/L (7.5 mmol/L), which intervention is most important for the nurse to implement?
The nurse observes a newly employed unlicensed assistive personnel (UAP) checking the temperature of an adult client using a tympanic thermometer.
The UAP pulls the client’s auricle up and back and prepares to insert the thermometer. Which action should the nurse implement?
The nurse is teaching a client about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
An older adult female client tells the clinic nurse about frequently awakening during the night and not being able to go back to sleep.
What action(s) should the nurse suggest to the client to help improve sleep? Select all that apply.
The healthcare provider prescribes streptomycin 200 mg IM every 12 hours.
The vial is labeled, “Streptomycin 1 gram/25.”. How many milliliters should the nurse administer? (Enter numerical value only.
If rounding is required, round to the nearest tenth.)
Explanation
Step 1: Calculate the volume to administer. 200 mg ÷ (1000 mg ÷ 25 mL) = 200 mg ÷ 40 mg/mL = 5 mL The nurse should administer 5 mL.
A nurse is reviewing a client’s laboratory results and notes a blood glucose result of 104 mg/dL (5.8 mmol/L). The reference range is 74 to 106 mg/dL (4.1 to 5.9 mmol/L). Which action should the nurse take?
A nurse is reviewing a client’s orders and notes the following: Vital signs every 4 hours, regular diet, Cefazolin 1g IV every 8 hours for 5 days, Metformin 1,000 mg PO every 12 hours, and point of care blood glucose check every 4 hours.
Which action should the nurse take?
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