Foundation HESI 3

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Sample questions from Foundation HESI 3

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

1. 1.At change of shift on a medical-surgical unit, a charge nurse receives report on four clients. Which client should the charge nurse assess first?

   • A.A 68-year-old with heart failure who has new confusion, SpO2 89% on room air, and an increase in respiratory rate from 18 to 28/min
   • B.A 54-year-old with diabetes whose premeal glucose is 248 mg/dL and who is awaiting a scheduled correction dose of insulin
   • C.A 45-year-old with pneumonia whose temperature is 38.1 C and who is due for the next dose of an ordered antipyretic
   • D.A 72-year-old on postoperative day 2 who reports incisional pain of 7/10 and has a dry dressing

   Rationale: New confusion with hypoxemia and an increased respiratory rate suggests acute deterioration and requires prompt assessment and intervention. The elevated glucose requires treatment, but the client is not described as unstable. Pain and fever need attention, but neither takes priority over impaired oxygenation and a change in mental status. Prioritize airway and breathing threats over stable, expected, or treatable symptoms.

2. 2.During a home visit, a community health nurse plans care for a 6-month-old infant with a feeding tube. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Assess the infant for signs of aspiration during a feeding
   • B.Teach the caregiver how to flush the tube before and after feeding
   • C.Measure and record the infant's weight using the same scale used at the prior visit
   • D.Determine whether the infant's feeding schedule needs to be changed

   Rationale: Obtaining and documenting a routine weight is a predictable task that can be delegated to a trained UAP, with the nurse interpreting the result. Assessing aspiration risk, teaching the caregiver, and deciding whether the plan should change require nursing judgment. The nurse should clarify the procedure for obtaining the weight and follow up on an unexpected result. Delegate tasks, not assessment, teaching, or evaluation.

3. 3.Refer to the client's chart. Which actions should the nurse take now to coordinate safe care for the client? Select all that apply.

   • A.Arrange routine transport to radiology before contacting the provider
   • B.Document the change in condition, the notifications made, and the client's response
   • C.Reassess the client's respiratory status and oxygen saturation after initiating the immediate interventions
   • D.Notify the rapid response team of the increasing respiratory distress and altered mental status
   • E.Stay with the client, position upright, and apply oxygen according to the emergency protocol while help arrives

   Rationale: The change from SpO2 94% to 88%, respiratory rate 20 to 30/min, and new difficulty staying awake warrants rapid escalation; the nurse should remain with the client, support breathing, and reassess response. Documenting objective findings and actions supports continuity and accountability. Routine radiology transport could delay stabilization and is not the first action during acute deterioration. Immediate stabilization and escalation take priority over routine diagnostic coordination.

4. 4.A provider prescribes digoxin for a 17-year-old client with a congenital heart condition. Before administering the scheduled dose, the nurse notes an apical pulse of 54/min and a serum digoxin level of 2.3 ng/mL (therapeutic range 0.5-2.0 ng/mL). Which action should the nurse take?

   • A.Give the dose with food and recheck the pulse in 1 hour
   • B.Give half the dose and document the adjustment
   • C.Ask the UAP to repeat the pulse and administer the dose if it is above 50/min
   • D.Withhold the dose and notify the provider of the pulse and serum level

   Answer and rationale are in the full material.

5. 5.In a pediatric clinic, the parent of a 4-year-old says the family cannot afford the newly prescribed inhaler and asks whether the child can use a relative's medication instead. Which response by the nurse best supports safe, coordinated care?

   • A.Advise the parent to reduce the prescribed number of inhalations to make the medication last longer
   • B.Ask the parent to bring the inhaler to the clinic, and arrange for the prescriber and a social worker or pharmacist to discuss safe, affordable options
   • C.Ask the parent to stop the child's other medications until the inhaler can be purchased
   • D.Tell the parent to use the relative's inhaler until the next scheduled appointment

   Answer and rationale are in the full material.