HESI266

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Sample questions from HESI266

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

1. 1.The nurse in the emergency department receives report on four clients. Which client should the nurse assess first?

   • A.A 62-year-old client with a history of COPD who is currently on 2L oxygen with a pulse oximetry of 89%.
   • B.A 19-year-old client with a closed head injury who was previously alert but is now difficult to arouse.
   • C.A 45-year-old client with chronic kidney disease who missed one dialysis session and has a potassium of 5.6 mEq/L.
   • D.A 30-year-old client reporting epigastric pain and three episodes of vomiting after a heavy meal.

   Rationale: Using the ABC (Airway, Breathing, Circulation) and neurological priority framework, the 19-year-old client with a head injury who has a declining level of consciousness (LOC) is the priority. A change in LOC indicates a possible increase in intracranial pressure or intracranial hemorrhage, which is life-threatening. The potassium of 5.6 mEq/L is elevated but not immediately lethal for a dialysis patient. The COPD client's oxygenation is within the expected range (88-92%) for that condition. The client with vomiting is stable and represents a lower priority than a neurological emergency.

2. 2.A charge nurse is making assignments for the day shift. Which client is most appropriate to assign to a Licensed Practical Nurse (LPN)?

   • A.A client with a history of stable heart failure who requires administration of scheduled oral furosemide.
   • B.A client with a new diagnosis of Type 1 Diabetes who requires education on insulin self-administration.
   • C.A client who underwent a total knee arthroplasty 24 hours ago and needs evaluation of the pain management plan.
   • D.A client who just returned from the cardiac catheterization lab and requires vital sign monitoring every 15 minutes.

   Rationale: LPNs are best assigned to stable clients with predictable outcomes. Administering oral medications to a stable client with heart failure is within the LPN scope of practice. Evaluating a pain management plan and providing initial teaching for a new diagnosis are complex tasks that require the judgment and assessment skills of an RN. Monitoring a client immediately post-procedure (post-cardiac cath) requires frequent assessment for acute complications (bleeding, hematoma), which is also an RN responsibility.

3. 3.During a home health visit, the nurse notes that a 78-year-old client with dementia and heart failure has new bruises in various stages of healing on the upper arms and back. The caregiver appears frustrated and states, 'It's just so hard to get them to sit still.' Which action should the nurse take first?

   • A.Discuss the possibility of placing the client in a long-term care facility.
   • B.Ask the caregiver to demonstrate how they assist the client with mobility.
   • C.Provide the caregiver with resources for respite care services.
   • D.Report the findings to the local adult protective services agency.

   Rationale: The nurse is a mandatory reporter. In cases where physical findings (bruises on the back/upper arms) and caregiver statements suggest potential abuse or neglect, the nurse must first fulfill the legal obligation to report the suspected abuse to the appropriate authorities (Adult Protective Services). While respite care and education are helpful, they do not address the immediate safety and legal requirements of the situation. Further assessment by the nurse does not replace the requirement to report.

4. 4.An 82-year-old client is admitted for a hip fracture. During the night, the client becomes agitated, pulls at the IV line, and attempts to climb out of bed. Which intervention should the nurse implement first?

   • A.Ask a family member to stay at the bedside with the client.
   • B.Administer the PRN dose of lorazepam.
   • C.Place the client in a room closer to the nurse's station.
   • D.Request a prescription for a soft wrist restraint.

   Answer and rationale are in the full material.

5. 5.Which task is most appropriate for the RN to delegate to an Unlicensed Assistive Personnel (UAP)?

   • A.Checking the skin integrity of a client under a compression dressing.
   • B.Obtaining a clean-catch urine specimen from a mobile client.
   • C.Assisting a client with their first ambulation after a bowel resection.
   • D.Feeding a client with dysphagia who just arrived from the PACU.

   Answer and rationale are in the full material.