HESI Nursing Concept 2

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Sample questions from HESI Nursing Concept 2

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

1. 1.At change of shift on a medical unit, a 68-year-old client with pneumonia has a temperature of 38.2 C, HR 104/min, RR 24/min, BP 118/70 mm Hg, and SpO2 91% on 2 L/min oxygen. Which client should the nurse assess first?

   • A.A client with pneumonia whose oxygen saturation has fallen from 95% to 91%
   • B.A client with chronic back pain requesting the prescribed analgesic
   • C.A client with diabetes whose premeal glucose is 218 mg/dL
   • D.A client awaiting discharge who needs medication instructions

   Rationale: The falling oxygen saturation and tachypnea indicate worsening respiratory status and require prompt assessment. Pain, moderate hyperglycemia, and discharge teaching are important but do not take priority over a potential airway or breathing problem. Use the ABC framework when prioritizing.

2. 2.Refer to the client's chart. Which action should the charge nurse take first to address the change in the client's condition?

   • A.Call the client's family to ask whether the client is usually confused
   • B.Document the findings and continue the scheduled medication pass
   • C.Notify the rapid response team and remain with the client
   • D.Ask the assistive personnel to obtain another set of vital signs in 30 minutes

   Rationale: The chart shows new confusion, hypotension, tachycardia, and a rising temperature, consistent with possible sepsis and deterioration. Activate the rapid response process and stay with the client while help arrives. Delayed rechecking, routine documentation, or contacting family first would postpone urgent assessment and treatment.

3. 3.During a home health visit, a 52-year-old client with a new colostomy says, "I do not know how to change this pouch by myself." The stoma is moist and red, and the peristomal skin is intact. Which response best supports safe discharge planning?

   • A.Recommend delaying discharge until the stoma becomes less red
   • B.Provide a printed guide and end the visit so the client can practice alone
   • C.Tell the client that a family member must perform all ostomy care
   • D.Arrange a return demonstration and assess the client's ability to manage the pouch

   Rationale: A return demonstration lets the nurse assess practical skill and identify barriers before planning additional support. A healthy stoma is moist and red, so its appearance alone does not justify delaying discharge. Assuming family must provide care or relying only on written material does not establish the client's ability.

4. 4.On a pediatric unit, a 9-year-old client with asthma is stable after treatment, while another client has just arrived with severe respiratory distress. Which tasks may the registered nurse delegate to experienced assistive personnel? Select all that apply.

   • A.Assist the stable client with bathing and dressing
   • B.Measure and record the stable client's intake and output
   • C.Assess the newly admitted client's breath sounds
   • D.Teach the newly admitted client how to use a metered-dose inhaler
   • E.Obtain routine vital signs for the stable client and report abnormal results

   Answer and rationale are in the full material.

5. 5.A provider prescribes an IV medication for a 46-year-old client, but the dose is far above the usual range and the client says, "I have never taken that much." The client is stable. What should the nurse do?

   • A.Ask another nurse to verify the dose and then administer it
   • B.Hold the medication and clarify the prescription with the provider
   • C.Administer the medication because the prescription is signed
   • D.Give half the prescribed dose and document the adjustment

   Answer and rationale are in the full material.