85894 HESI

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Sample questions from 85894 HESI

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

   • A.A 53-year-old client receiving antibiotics for cellulitis who has a temperature of 38.0 C and stable vital signs
   • B.A 68-year-old client with heart failure who has gained 1 kg in 24 hours and reports new shortness of breath
   • C.A 45-year-old client 1 day after a cholecystectomy who rates incisional pain as 7 out of 10
   • D.A 72-year-old client with diabetes whose blood glucose is 248 mg/dL before breakfast

   Rationale: New shortness of breath with rapid weight gain may indicate worsening fluid overload and impaired oxygenation, so this client needs immediate assessment. The postoperative client needs pain management, but the reported pain is not as urgent as a possible respiratory complication. The elevated glucose and low-grade fever require follow-up, but neither finding indicates the same immediate threat based on the information provided. Prioritize new or worsening threats to airway and breathing.

2. 2.Refer to the client's chart. A 29-year-old client is 2 hours postpartum in the obstetric unit. Which actions should the nurse take now? Select all that apply.

   • A.Maintain or establish large-bore intravenous access and prepare to administer prescribed fluids.
   • B.Assist the client to the bathroom to void before reassessing the bleeding.
   • C.Call for immediate assistance and activate the obstetric hemorrhage response.
   • D.Massage the uterine fundus while assessing its tone.
   • E.Document the findings at the end of the shift before notifying the provider.

   Rationale: The chart shows increasing bleeding, a boggy fundus, tachycardia, and a falling blood pressure, which indicate postpartum hemorrhage and require an immediate team response. Fundal massage addresses uterine atony, and large-bore intravenous access supports rapid fluid or blood-product administration as prescribed. Taking the client to the bathroom could delay treatment and create a fall risk, while waiting to notify the provider would dangerously postpone escalation. Document actions and findings promptly, but documentation must not delay emergency care.

3. 3.During a home visit, a 76-year-old client with limited mobility needs help bathing and dressing. The registered nurse is coordinating care with an experienced unlicensed assistive personnel (UAP). Which task is appropriate to delegate to the UAP?

   • A.Obtain and record the client's routine morning weight using the established procedure.
   • B.Evaluate whether the client's new weakness is related to a recent medication change.
   • C.Assess the client's skin for pressure injury and determine whether the care plan needs revision.
   • D.Teach the client how to use a newly prescribed walker.

   Rationale: Obtaining and recording a routine weight is a predictable task that can be delegated to a trained UAP, with the registered nurse responsible for interpreting the result. Evaluating weakness and assessing skin require nursing judgment and cannot be delegated. Teaching use of a new walker also requires nursing assessment and instruction. Delegation depends on the task, the client's stability, and the delegatee's demonstrated competence.

4. 4.Before a scheduled procedure in the outpatient surgery center, a 41-year-old client tells the nurse, "I signed the form, but I still do not understand the main risks." The client is alert and has stable vital signs. What should the nurse do?

   • A.Ask the client's family member to explain the risks because the client has already signed.
   • B.Witness the existing signature and transport the client to the procedure room.
   • C.Explain the procedure's risks using the consent form, then ask the client to sign again.
   • D.Notify the procedural provider that the client needs further explanation before proceeding.

   Answer and rationale are in the full material.

5. 5.A provider prescribes an anticoagulant for a 63-year-old client admitted with a deep vein thrombosis. During the medication check, the nurse sees that the client's platelet count has fallen from 220,000/mm3 to 82,000/mm3 in 2 days. The client reports new bruising and has stable vital signs. What is the nurse's priority action?

   • A.Give the medication with food to reduce the chance of bleeding.
   • B.Ask the UAP to repeat the platelet count before deciding whether to give the medication.
   • C.Hold the medication and promptly contact the provider about the platelet decline and bruising.
   • D.Administer the prescribed dose and recheck the platelet count tomorrow.

   Answer and rationale are in the full material.