HESI Exam 2 Family Nursing

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Sample questions from HESI Exam 2 Family Nursing

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.At change of shift on a postpartum unit, report identifies four clients. Which client should the nurse assess first?

   • A.A client 8 hours after birth reporting perineal pain rated 6 of 10
   • B.A client 2 hours after birth with a saturated perineal pad in 15 minutes and a boggy uterus
   • C.A client 12 hours after birth with a temperature of 37.7 C (99.9 F)
   • D.A client 1 day after birth asking for help with breastfeeding

   Rationale: A saturated pad and boggy uterus suggest postpartum hemorrhage, which can rapidly cause hypovolemic shock. Pain, a mildly elevated temperature in the first 24 hours, and breastfeeding assistance are important but are not as immediately life-threatening. Assess uterine tone and bleeding and initiate hemorrhage interventions promptly.

2. 2.During a home visit, a public health nurse finds that a 79-year-old client with heart failure has gained 2.3 kg (5 lb) in 3 days and reports new breathlessness when lying flat. Which action is the priority?

   • A.Notify the health care provider about the weight gain and worsening dyspnea
   • B.Schedule a routine follow-up visit in 2 weeks
   • C.Recommend reducing fluid intake to 1 L daily without consulting the provider
   • D.Teach the client to weigh weekly rather than daily

   Rationale: Rapid weight gain with orthopnea can indicate worsening fluid overload and requires prompt clinical follow-up. The nurse should not independently prescribe a fluid limit, and delaying evaluation or reducing monitoring could worsen outcomes. Daily weights are a useful part of heart-failure self-management.

3. 3.In a pediatric clinic, a parent reports that a 6-year-old with asthma has used a rescue inhaler every 3 hours today and is still wheezing. The child is alert, has an SpO2 of 93% on room air, and speaks in short phrases. Which action should the nurse take first?

   • A.Teach the child to avoid exercise until the wheezing resolves
   • B.Ask the parent to schedule a routine visit with the primary care provider
   • C.Arrange immediate evaluation and initiate the clinic's acute asthma protocol
   • D.Review the child's written asthma action plan at the next appointment

   Rationale: Persistent wheezing despite frequent rescue medication, reduced oxygen saturation, and difficulty speaking indicate an acute exacerbation requiring immediate treatment. Routine teaching and follow-up do not address the current respiratory distress. Avoiding exercise is not a substitute for emergency assessment and treatment.

4. 4.Refer to the client's chart. Which actions should the nurse take now for this client? Select all that apply.

   • A.Assess fundal tone and perform fundal massage if the uterus is boggy
   • B.Call for assistance and notify the obstetric clinician of continued heavy bleeding
   • C.Prepare to administer the prescribed uterotonic medication
   • D.Encourage the client to walk to the bathroom before reassessing bleeding
   • E.Document the amount and characteristics of blood loss

   Answer and rationale are in the full material.

5. 5.A charge nurse on a medical unit is assigning care for the shift. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Assess a newly admitted client reporting sudden chest pressure
   • B.Evaluate a client's response to an IV opioid
   • C.Teach a client how to use a newly prescribed walker
   • D.Obtain routine vital signs for a stable client 1 day after an uncomplicated surgery

   Answer and rationale are in the full material.