Foundation HESI2

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Sample questions from Foundation HESI2

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, the nurse receives report on four clients. Which client should the nurse assess first?

   • A.A 54-year-old with chronic obstructive pulmonary disease, with SpO2 90% on the prescribed 2 L/min oxygen and no change from baseline
   • B.A 67-year-old who is 6 hours postoperative from a colectomy, with urine output of 25 mL/hr for 2 hours and BP 108/64 mm Hg
   • C.A 45-year-old with pancreatitis who reports pain of 8/10 one hour after receiving the prescribed analgesic
   • D.A 72-year-old receiving a heparin infusion who has new confusion and a platelet count that decreased from 210,000/mm3 to 92,000/mm3

   Rationale: The client receiving heparin has a greater than 50% platelet decline and new confusion, findings concerning for heparin-induced thrombocytopenia with possible thrombosis or bleeding; prompt assessment and escalation are needed. The postoperative oliguria requires timely follow-up, but the reported BP is not as immediately concerning as the acute neurologic change with thrombocytopenia. The COPD client's oxygenation is at baseline, and the client's pain requires reassessment but is not the highest priority.

2. 2.Refer to the client's chart. Which actions should the nurse take now for the 16-year-old client? Select all that apply.

   • A.Notify the provider promptly about the potassium level and electrocardiogram changes.
   • B.Place the client on a cardiac monitor and obtain a 12-lead electrocardiogram.
   • C.Encourage the client to drink water and repeat the potassium level in 4 hours.
   • D.Administer the prescribed IV insulin with dextrose after verifying the dose and monitoring plan.
   • E.Stop the potassium-containing intravenous fluid and maintain venous access with a compatible solution.

   Rationale: The potassium rose from 5.2 to 6.4 mEq/L while the client received potassium-containing fluid, and peaked T waves are present, so the infusion should be stopped, cardiac monitoring and an ECG are needed, and the provider should be notified promptly. Prescribed IV insulin with dextrose can shift potassium into cells and is appropriate with verification and monitoring for hypoglycemia. Oral fluids and waiting 4 hours would delay treatment of a potentially life-threatening dysrhythmia risk.

3. 3.During a home visit, a 79-year-old client with heart failure says, "I feel fine, but I stopped taking the water pill because I cannot get to the bathroom in time." The client has gained 2.3 kg (5 lb) in 4 days, has new ankle edema, and has BP 148/86 mm Hg. Which nursing action is best?

   • A.Tell the client to resume the prescribed dose and take it at bedtime to avoid missing doses.
   • B.Assess the client's breathing, lung sounds, medication access, and ability to toilet, then promptly contact the prescriber about the weight gain and stopped medication.
   • C.Ask the client to restrict fluids to 500 mL/day until the edema resolves.
   • D.Arrange for a weekly weight check and discuss the medication concern at the next scheduled visit.

   Rationale: The rapid weight gain and new edema suggest worsening fluid retention, while the client has stopped a prescribed diuretic because of a practical barrier. Assessing for current decompensation and promptly communicating the findings supports safe, individualized management without independently changing the regimen. Bedtime dosing may worsen nocturia, severe fluid restriction is not justified without an order, and waiting a week could delay needed intervention.

4. 4.In the emergency department, a 31-year-old client with a suspected ectopic pregnancy has BP 86/52 mm Hg, HR 128/min, cool clammy skin, and increasing abdominal pain. Which action should the nurse take first?

   • A.Provide written information about treatment options for ectopic pregnancy.
   • B.Prepare the client for transvaginal ultrasonography before starting treatment.
   • C.Establish large-bore IV access and initiate the prescribed isotonic fluid bolus while summoning the emergency team.
   • D.Obtain a detailed menstrual and contraception history.

   Answer and rationale are in the full material.

5. 5.A 3-year-old in a community clinic is being evaluated for a febrile illness. The child is alert, has a temperature of 38.4 C, and has a nonblanching purple rash on the legs; the parent reports that the rash spread over the past hour. Which action is the priority?

   • A.Place the child in a private room, institute appropriate precautions, and alert the provider immediately.
   • B.Give the parent instructions for alternating acetaminophen and ibuprofen at home.
   • C.Collect a routine throat culture before contacting the provider.
   • D.Ask the parent to photograph the rash and return if it spreads further.

   Answer and rationale are in the full material.