Fon HESI

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Sample questions from Fon HESI

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

1. 1.During a home visit, a 6-month-old infant with a ventricular septal defect is due for a scheduled feeding. The parent reports that the infant has taken less than half of each bottle today and is sweating during feeds. The infant is awake, with HR 168/min, RR 62/min, BP 78/46 mm Hg, and SpO2 91% on room air. Which action should the nurse take first?

   • A.Assess the infant's respiratory effort and notify the provider of the change in status.
   • B.Teach the parent to increase the caloric density of the formula.
   • C.Ask the parent to finish the prescribed feeding before the next dose of medication.
   • D.Arrange a routine dietitian referral for the next clinic visit.

   Rationale: Tachypnea, tachycardia, diaphoresis with feeding, reduced intake, and low oxygen saturation suggest worsening heart failure and require prompt assessment and escalation. Completing a feeding could increase the infant's work of breathing, while formula changes and a routine referral do not address the immediate deterioration. In a home setting, recognize acute change, assess the airway and breathing, and promptly contact the appropriate clinician.

2. 2.At change of shift on a medical unit, the charge nurse receives reports about four clients. Which client should the nurse assess first?

   • A.A 15-year-old with a forearm fracture who reports pain of 8/10 one hour after receiving an opioid; RR 16/min and SpO2 98%.
   • B.A 32-year-old at 30 weeks of pregnancy with a severe headache and blurred vision; BP 168/112 mm Hg and new clonus.
   • C.A 46-year-old with pneumonia whose temperature is 38.2 C and who is due for an antipyretic; BP 122/76 mm Hg and SpO2 95% on 2 L/min.
   • D.A 4-year-old with gastroenteritis who has had two loose stools and is asking for a drink; HR 112/min and capillary refill 2 seconds.

   Rationale: Severe-range blood pressure with headache, visual symptoms, and clonus in pregnancy suggests preeclampsia with severe features and risk of seizure or stroke, making this the priority. The child with diarrhea has no reported signs of shock, and the fracture client needs timely pain reassessment but has stable respiratory findings. The client with pneumonia is febrile but has stable blood pressure and oxygenation, so the antipyretic can follow the urgent assessment.

3. 3.In a rehabilitation unit, an RN is assigning tasks for a 28-year-old client recovering from a stroke who has right-sided weakness, mild dysphagia, and stable vital signs. Which tasks may the RN delegate to an experienced unlicensed assistive personnel (UAP)? Select all that apply.

   • A.Position the client upright for a meal after the RN has confirmed the prescribed diet and swallowing plan.
   • B.Obtain routine vital signs and report readings outside the parameters set by the RN.
   • C.Teach the client how to use the call light before getting out of bed.
   • D.Evaluate whether the client's cough is effective after a meal.
   • E.Assist the client with a previously assessed, prescribed transfer using a gait belt.
   • F.Measure and record the client's intake and output during the shift.

   Rationale: A UAP may collect and report routine data, assist with a transfer that has already been assessed and planned, and position the client according to an established swallowing plan. Evaluating cough effectiveness requires nursing assessment, and teaching about safe mobility is an RN responsibility. Delegation transfers task performance, not assessment, evaluation, or teaching accountability.

4. 4.A provider prescribes IV potassium chloride for a 73-year-old client with potassium 2.8 mEq/L (reference range 3.5 to 5.0 mEq/L). The client has chronic kidney disease, urine output of 15 mL/hr for the past 2 hours, and a current creatinine of 2.4 mg/dL (reference range 0.6 to 1.2 mg/dL). Which action should the nurse take?

   • A.Administer the potassium through the closest available IV port to correct the level quickly.
   • B.Ask the UAP to obtain another urine output measurement before starting the infusion.
   • C.Hold the infusion and clarify the prescription with the provider.
   • D.Dilute the potassium in a smaller volume to reduce fluid exposure.

   Answer and rationale are in the full material.

5. 5.In a long-term care facility, an 81-year-old resident with dementia and a history of falls is found sitting on the floor beside the bed. The resident is awake and says, "I feel fine," but has a new 3-cm scalp swelling and takes warfarin. BP is 138/76 mm Hg, HR 84/min, and SpO2 97% on room air. Which action should the nurse take first?

   • A.Assist the resident back to bed and complete the incident report.
   • B.Call the family before beginning an assessment so they can provide the resident's baseline.
   • C.Ask the UAP to perform neurologic checks every 4 hours.
   • D.Assess the resident for injury and neurologic changes, then notify the provider promptly.

   Answer and rationale are in the full material.