Foundation HESI 2

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Sample questions from Foundation HESI 2

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 68-year-old client with heart failure, chronic kidney disease, and atrial fibrillation is due for digoxin. The client reports new nausea and seeing yellow halos; the apical pulse is 54/min, potassium is 3.1 mEq/L (reference range 3.5-5.0), and the digoxin level is pending. Which action should the nurse take first?

   • A.Withhold the digoxin and notify the provider of the findings.
   • B.Give the scheduled potassium supplement and administer digoxin afterward.
   • C.Ask the nursing assistant to repeat the apical pulse before giving the medication.
   • D.Administer the prescribed digoxin and reassess the pulse in 1 hour.

   Rationale: Withholding digoxin and promptly notifying the provider is safest because bradycardia, nausea, visual changes, and hypokalemia suggest possible digoxin toxicity. Giving digoxin after potassium or waiting for a repeat pulse could delay care while the client remains at risk for dysrhythmia. A nursing assistant cannot make the medication-administration decision, and the nurse should not delegate assessment of this potential adverse effect.

2. 2.During a home visit, a 7-year-old with type 1 diabetes is pale and shaky before lunch. The child is awake and able to swallow; the continuous glucose monitor reads 52 mg/dL, and the parent says the child received the usual insulin but ate little breakfast. Which instruction should the nurse give the parent to do first?

   • A.Call emergency services before giving anything by mouth.
   • B.Give the scheduled lunch insulin now so the meal can be served promptly.
   • C.Offer a protein snack and recheck the glucose in 1 hour.
   • D.Give 15 g of fast-acting carbohydrate and recheck glucose in 15 minutes.

   Rationale: The child has symptomatic hypoglycemia but is alert and can swallow, so fast-acting carbohydrate followed by a glucose recheck in 15 minutes is the immediate action. Insulin could worsen the low glucose, and protein alone does not correct it rapidly. Emergency services are not the first step for an alert child who can safely take oral carbohydrate, though escalation is needed if the child cannot swallow or does not improve.

3. 3.Refer to the client's chart. Which actions should the nurse take now for this 56-year-old client on a postoperative unit? Select all that apply.

   • A.Activate the rapid response system for acute clinical deterioration.
   • B.Stay with the client and promptly communicate the change in status using a structured handoff.
   • C.Ask the nursing assistant to assess whether the client is becoming more difficult to arouse.
   • D.Administer the prescribed opioid now because the client reports incisional pain.
   • E.Apply oxygen and continuously monitor oxygen saturation while awaiting the response team.

   Rationale: The client's falling blood pressure, increasing heart rate, declining oxygen saturation, and new confusion indicate acute deterioration; activate rapid response, support oxygenation, and stay to communicate the changes. The opioid could worsen respiratory depression in a client whose respiratory rate and oxygenation are declining, so it is not appropriate before reassessment and stabilization. Assessment of changing alertness requires a licensed nurse rather than delegation to the nursing assistant.

4. 4.In a long-term care facility, a 79-year-old resident with dementia and a recent urinary tract infection has a temperature of 38.4 C, HR 112/min, BP 94/58 mm Hg, and new lethargy. The resident's usual systolic pressure is 130-140 mm Hg. Which action should the charge nurse take first?

   • A.Encourage oral fluids and reassess the resident at the end of the shift.
   • B.Arrange urgent emergency evaluation for possible sepsis.
   • C.Call the family to ask whether the resident is usually sleepy after lunch.
   • D.Ask the nursing assistant to obtain another temperature in 30 minutes.

   Answer and rationale are in the full material.

5. 5.The provider prescribes IV potassium chloride for a 35-year-old client with vomiting and a potassium level of 2.8 mEq/L (reference range 3.5-5.0). The client has a peripheral IV, urine output of 25 mL/hr for 3 hours, and an estimated glomerular filtration rate of 28 mL/min/1.73 m2. Which action should the nurse take before administering the potassium?

   • A.Begin the infusion at the prescribed rate and repeat the potassium level in 4 hours.
   • B.Ask the pharmacist to prepare the potassium in a smaller volume.
   • C.Clarify the prescription with the provider and report the low urine output and renal impairment.
   • D.Give the potassium by IV push because the level is below 3.0 mEq/L.

   Answer and rationale are in the full material.