HESI R

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Sample questions from HESI R

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

1. 1.In the emergency department, a 68-year-old client with diabetes reports nausea and unusual fatigue rather than chest pain. The client is pale and diaphoretic; HR is 112/min, BP is 88/54 mm Hg, and SpO2 is 94% on room air. Another client with a closed ankle fracture is asking for pain medication. Which action should the charge nurse take first?

   • A.Ask an unlicensed assistive personnel (UAP) to obtain a complete medical history from the client with diabetes.
   • B.Place the client with diabetes in the waiting area while obtaining a repeat blood pressure.
   • C.Assign a nurse to obtain a 12-lead ECG and initiate the chest-pain protocol for the client with diabetes.
   • D.Ask the nurse caring for the client with the ankle fracture to administer the prescribed analgesic.

   Rationale: The combination of hypotension, tachycardia, pallor, diaphoresis, and atypical symptoms in a client with diabetes may indicate acute coronary syndrome with hemodynamic compromise, so rapid ECG and protocol-based evaluation are priorities. Treating the fracture pain is appropriate but can wait while the unstable client is assessed. Waiting for another blood pressure delays evaluation, and obtaining a complete history is not the immediate priority.

2. 2.On a medical-surgical unit, a 54-year-old client who had an uncomplicated laparoscopic cholecystectomy 8 hours ago is alert, tolerating clear liquids, and has a clean, dry dressing. The RN has four clients and a UAP is available. Which task is appropriate for the RN to delegate to the UAP?

   • A.Assist the client to ambulate in the hallway after confirming the client is not dizzy.
   • B.Teach the client how to splint the incision when coughing.
   • C.Evaluate whether the client is tolerating oral fluids without nausea.
   • D.Assess the client's abdominal pain before the next analgesic dose.

   Rationale: Assisting a stable client with ambulation is a routine task that can be delegated after the RN has determined the client is safe to mobilize. Pain assessment, teaching, and evaluation of fluid tolerance require nursing judgment and remain the RN's responsibility. The RN should communicate the client's mobility status and instruct the UAP to report dizziness or a change in condition promptly.

3. 3.Refer to the client's chart. Which actions should the charge nurse take in response to the client's current condition? Select all that apply.

   • A.Delegate assessment of uterine tone to the LPN while the RN attends another client.
   • B.Ask the UAP to quantify the lochia and report the measured amount to the RN.
   • C.Notify the obstetric provider promptly about the persistent hypotension and increasing heart rate.
   • D.Remain with the client and initiate the facility's postpartum hemorrhage response.
   • E.Document the findings and wait 30 minutes before notifying the provider if the client remains alert.

   Rationale: The chart shows increasing heart rate, falling blood pressure, and increasing quantified blood loss, which require immediate escalation and activation of the postpartum hemorrhage response. The UAP can measure and report lochia, but the RN must interpret the findings and assess uterine tone. Delegating uterine-tone assessment to the LPN is inappropriate in this rapidly changing situation, and waiting to notify the provider could delay life-saving treatment.

4. 4.During a home visit, a 76-year-old client with heart failure says, 'I stopped taking the water pill because I cannot get to the bathroom quickly.' The client has new ankle edema, gained 2.3 kg (5 lb) in 4 days, and has a BP of 146/84 mm Hg. Which action by the home health nurse is best?

   • A.Tell the client to take twice the prescribed dose today to remove the extra fluid.
   • B.Assess respiratory status and medication access, then contact the prescriber about the missed doses and weight gain.
   • C.Document the client's preference and plan to reassess at the next scheduled visit.
   • D.Ask a family member to administer the medication without discussing the client's concerns.

   Answer and rationale are in the full material.

5. 5.At change of shift on a long-term care unit, a 9-year-old client with cerebral palsy is stable, has a gastrostomy tube, and receives a scheduled enteral feeding. An LPN, a UAP, and an RN are available. Which task is appropriate for the RN to assign to the LPN?

   • A.Perform the initial assessment of a newly admitted resident with respiratory distress.
   • B.Develop a revised care plan for the client's recurrent aspiration.
   • C.Evaluate the client's response to a newly initiated feeding regimen.
   • D.Administer the scheduled enteral feeding to the stable client according to the established plan.

   Answer and rationale are in the full material.