Data Collection Health HESI

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Sample questions from Data Collection Health HESI

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 72-year-old client with pneumonia has a temperature of 38.4 C, HR 112, RR 30, BP 88/54, and SpO2 90% on 2 L/min by nasal cannula. Which action should the nurse take first?

   • A.Call the client's family to obtain the client's baseline status
   • B.Document the findings and recheck the vital signs in 30 minutes
   • C.Obtain a sputum specimen before administering the next antibiotic
   • D.Assess the client's airway and breathing and increase oxygen as indicated by protocol

   Rationale: The low blood pressure, tachycardia, tachypnea, and falling oxygenation signal possible acute deterioration, so immediate assessment and support of oxygenation take priority. Obtaining a specimen may be appropriate but must not delay stabilization. Family history and delayed rechecking do not address the immediate threat.

2. 2.During a home visit, a 68-year-old client with heart failure reports worsening shortness of breath. The client has gained 2.3 kg (5 lb) in 3 days, has bilateral ankle edema, and has a respiratory rate of 26/min. Which findings should the nurse include in the focused assessment? Select all that apply.

   • A.Lung sounds in all fields
   • B.Ability to lie flat and number of pillows used
   • C.Whether the client has a preferred brand of shoes
   • D.Daily weight trend and usual baseline
   • E.Color of the client's bed linens
   • F.Recent sodium and fluid intake

   Rationale: Lung sounds, intake, weight trend, and orthopnea help evaluate fluid accumulation and worsening heart failure. Shoe preference and linen color do not contribute to the urgent focused assessment. A change in breathing or rapid weight gain warrants prompt follow-up.

3. 3.In the emergency department, a 45-year-old client arrives after a fall and reports neck pain and tingling in both hands. BP is 138/82, HR 96, RR 20, and SpO2 98%. Which action best protects the client while the assessment proceeds?

   • A.Maintain cervical spine alignment and use spinal motion restriction
   • B.Place a pillow under the neck and flex the head forward
   • C.Assist the client to stand so gait can be assessed
   • D.Ask the client to turn the head to identify the painful side

   Rationale: Neck pain with bilateral paresthesias after a fall raises concern for cervical spine injury, so alignment and spinal motion restriction are priorities. Turning the head or standing could worsen an injury. Neck flexion is also inappropriate until the spine has been evaluated.

4. 4.A provider prescribes a medication for a 59-year-old client, but the electronic record lists a severe allergy to that medication. The client is alert and the dose is due now. What should the nurse do?

   • A.Document the allergy and administer the medication as prescribed
   • B.Withhold the medication and clarify the prescription with the provider
   • C.Give half the dose and monitor for a reaction
   • D.Ask the client whether the allergy is still present

   Answer and rationale are in the full material.

5. 5.On a pediatric unit, a 7-year-old with a new seizure disorder is ready for discharge. The caregiver says, 'I am not sure I can give the rescue medicine.' Which action best evaluates readiness for discharge?

   • A.Ask the caregiver to repeat the name of the medicine
   • B.Give the caregiver a printed medication list
   • C.Ask the caregiver to demonstrate how to administer the rescue medicine
   • D.Schedule a routine follow-up appointment

   Answer and rationale are in the full material.