HESI Exam 2 NSG233

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Sample questions from HESI Exam 2 NSG233

This material has 75 questions with answers and rationales. Here are the first 5.

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

   • A.A 9-year-old with a forearm fracture who reports pain of 8 on a 0-to-10 scale; the next analgesic dose is due
   • B.A 12-year-old with asthma whose peak expiratory flow is 75% of personal best and who is speaking in full sentences
   • C.A 6-year-old 4 hours after tonsillectomy who is swallowing repeatedly and becoming restless
   • D.A 3-year-old with gastroenteritis who has had one loose stool in the past hour and is drinking oral rehydration solution

   Rationale: Repeated swallowing and restlessness after tonsillectomy can signal occult hemorrhage, which may progress rapidly before blood is visible. The fracture pain needs timely assessment and prescribed analgesia, but it is not the immediate threat described. The child with gastroenteritis is tolerating fluids, and the asthma findings do not indicate severe respiratory compromise. Prioritize subtle cues of airway or circulatory deterioration over expected pain or stable symptoms.

2. 2.During a home-health visit, a 71-year-old client with heart failure reports new fatigue and has a blood pressure of 118/70 mm Hg, pulse of 84/min, and oxygen saturation of 96% on room air. Which task is appropriate for the registered nurse to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Evaluate the client's understanding of sodium restriction
   • B.Teach the client how to adjust the diuretic dose when weight increases
   • C.Determine whether the fatigue is related to worsening heart failure
   • D.Obtain the client's weight and report it along with the previous day's weight to the nurse

   Rationale: A UAP may collect and report objective data, such as a daily weight, while the RN interprets the findings and assesses the new fatigue. Determining the cause of fatigue and evaluating understanding require nursing judgment. Teaching medication adjustment is also outside the UAP role and should not be delegated. The RN remains accountable for interpreting the weight trend and responding to any clinically significant change.

3. 3.Refer to the client's chart. Which actions should the charge nurse take now to coordinate a safe response to the client's change in condition? Select all that apply.

   • A.Ask the UAP to increase the oxygen flow rate based on the new saturation
   • B.Assign a second RN to obtain a focused assessment and repeat vital signs while the primary RN stays with the client
   • C.Ask the UAP to assess the client's level of consciousness and report whether it has worsened
   • D.Notify the provider with the change in mental status, vital-sign trend, and current oxygen requirement
   • E.Wait for the scheduled provider rounds because the client is already receiving oxygen
   • F.Contact the rapid response team using the facility's escalation criteria

   Rationale: The chart shows new confusion, a rising respiratory rate, falling oxygen saturation, and a new oxygen requirement, so an RN should promptly reassess while the rapid response process is activated. The provider should receive a concise report of the trend and interventions already in place. Assessing mental status and changing oxygen therapy require nursing assessment or clinical judgment, so they are not appropriate UAP tasks. Waiting for routine rounds delays escalation despite evidence of deterioration.

4. 4.In a surgical clinic, a 42-year-old client scheduled for a procedure says, "I signed the form, but I still do not understand what the surgeon plans to remove." The client is alert, and transport is waiting. What is the nurse's best action?

   • A.Pause the transfer and notify the surgeon that the client needs further explanation before proceeding
   • B.Continue the transfer because the signed consent confirms the client's understanding
   • C.Explain the procedure using the consent form and ask the client to sign again
   • D.Ask the client's spouse to explain the procedure so the scheduled time is not missed

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which action should the charge nurse take first to protect the client and coordinate care?

   • A.Ask the UAP to repeat the blood glucose in 30 minutes before notifying anyone
   • B.Ask the bedside RN to remain with the client and immediately activate the facility's emergency response process
   • C.Wait for the provider to review the morning laboratory results during rounds
   • D.Call the family to obtain consent for emergency treatment before escalating care

   Answer and rationale are in the full material.