HESI Fundamentals - Set 1 - Part 2

Correct Answer: Patient with new shortness of breath

New shortness of breath signals a possible breathing problem, which is a top ABC concern. The cue is acute and unstable, so the nurse must assess this patient first before any of the others. Option a is incorrect because Chronic stable arthritis pain represents an established baseline, not an acute change. The patient is not at immediate risk, so the assessment can wait until acutely ill patients have been evaluated. Option b is incorrect because A patient sleeping after a settled headache shows resolution rather than active distress. While the nurse will eventually round, this patient does not signal an urgent change and can wait safely. Option c is incorrect because Routine discharge teaching is important but never an emergency. The patient awaiting teaching is stable and safe, so the nurse can pick up that task once urgent ABC concerns have been addressed.

Correct Answer: Chest pressure with diaphoresis and concern

Chest pressure with diaphoresis suggests a possible cardiac event, ranking highest under ABC priorities. Physiologic and acute circulatory threats always come before love, esteem, and self-actualization needs in patient prioritization. Option a is incorrect because Loneliness sits in the love and belonging tier of Maslow, far below physiologic emergencies. The need is real but does not threaten survival, so it cannot outrank possible cardiac symptoms in any patient. Option c is incorrect because Self-image concerns belong to the esteem layer of Maslow, addressed only after physiologic and safety needs are stable. The nurse cannot ethically place an esteem issue ahead of suspected cardiac compromise. Option d is incorrect because Career planning belongs to self-actualization, the highest tier of Maslow. Such concerns are valid but never override an active physiologic threat, since survival itself is required before pursuing higher goals.

Correct Answer: Acute pain rated seven of ten

Acute pain is an actual, current problem with a high rating that drives many other complications. Untreated severe pain affects breathing, mobility, and recovery, so the nurse addresses this real issue first now. Option a is incorrect because Mild loneliness is real but emotional and lower on Maslow than acute pain. The need can be addressed alongside other care once the more pressing physiologic discomfort has been treated and is decreasing. Option b is incorrect because Risk for falls is a potential problem and the screening score is low, suggesting limited urgency. Risk diagnoses generally yield to actual problems with active cues unless the risk is imminent and severe. Option d is incorrect because Risk for boredom is not even a typical priority diagnosis on a busy unit. It pales in comparison to severe acute pain that is actively impairing function and recovery for this patient right now.

Correct Answer: Recording vital signs on a stable patient

Recording vital signs on a stable patient sits squarely within unlicensed assistive personnel scope. The task is routine, predictable, and requires no nursing judgment, making it safe to delegate during the shift. Option b is incorrect because Teaching insulin self-injection requires the registered nurse because patient education involves assessment of learning, evaluation of return demonstration, and clinical judgment. Assistive personnel cannot perform that level of teaching. Option c is incorrect because An admission head-to-toe assessment is a registered nurse responsibility that establishes baseline clinical data. The judgment and physical assessment skills required exceed unlicensed assistive personnel scope of practice anywhere. Option d is incorrect because Adjusting an intravenous infusion rate is a licensed nurse task, often a registered nurse one. Unlicensed personnel cannot manipulate medication delivery devices because errors carry serious patient safety consequences immed

Correct Answer: Monitor neutropenic patient for infection cues

A neutropenic patient with new cough faces imminent severe infection risk. Even subtle cues may signal bacteremia, so close monitoring outranks comfort tasks because untreated sepsis can deteriorate quickly into shock. Option a is incorrect because Constipation management matters but is chronic and stable. Repositioning and fluids can wait while the nurse evaluates a patient who is at far higher risk for life-threatening systemic infection right now. Option b is incorrect because Scheduled pain medication for stable post-op pain is routine and not time-critical to the minute. The nurse can administer that dose once the higher-risk neutropenic patient has been carefully assessed first. Option c is incorrect because Documentation is necessary but never the highest priority when an unstable risk situation exists. Charting waits while the nurse responds to the patient with the most imminent and severe potential harm.

Correct Answer: Keep call light and items within reach

Keeping the call light and personal items within reach is part of universal fall precautions for every patient. The action prevents reaching, climbing, and unsafe transfers regardless of formal risk-screen score. Option a is incorrect because Wrist restraints are not a universal fall precaution and require an order plus failed least-restrictive alternatives. Restraints can actually increase fall injury severity if a patient still attempts to move. Option b is incorrect because Side-lying position is sometimes used for aspiration risk but is not a universal fall precaution. Many patients require head-of-bed elevation or upright positioning, so this is not appropriate for everyone. Option d is incorrect because Continuous sitter use for every patient is impractical and not standard. Sitters are reserved for patients with documented unsafe behavior or impaired judgment, not as a universal precaution on the unit.

Correct Answer: Eighty-year-old confused after recent opioid

Older age, new confusion, and recent opioid sedation combine multiple major fall risk factors at once. The patient is the most likely to fall and needs targeted prevention measures rather than universal ones. Option b is incorrect because A forty-year-old who is ambulating without difficulty has no major risk factors for falls. The nurse still applies universal precautions, but the targeted prevention plan is not necessary for this patient. Option c is incorrect because A thirty-year-old preparing for routine discharge is generally stable and at low fall risk. Without sedation, mobility deficit, or cognitive change, the screening would not place the patient at high risk. Option d is incorrect because A fifty-year-old asleep with steady vital signs is currently stable and low risk while in bed. The nurse will monitor on rounds, but no targeted high-risk fall plan applies right now to the patient.

Correct Answer: Lower bed, sit, address patient need

Lowering the bed, providing a one-to-one presence, and addressing the underlying need such as toileting or pain reduces both the urge to climb and injury severity if a fall occurs. Option a is incorrect because Raising all four side rails functions as a restraint and increases injury height when the patient climbs over. Many serious falls occur when the patient tumbles over rails to reach the floor. Option c is incorrect because A vest restraint should not be applied without exhausting less restrictive alternatives and obtaining an order. Restraints have caused asphyxia and entrapment, especially in confused patients who continue trying to move. Option d is incorrect because Documenting the bed setting alone does not address the active climbing behavior. The nurse must intervene first by being present and meeting the underlying need, then chart the action and patient response.

Correct Answer: Assess injury and vitals before moving

Assessing for injury, level of consciousness, and vital signs before moving the patient is the standard post-fall response. Lifting too soon can worsen a hidden fracture, head injury, or hemodynamic problem. Option a is incorrect because Helping the patient stand and walk before assessment risks worsening any fracture or head injury. The nurse must rule out spinal, hip, or limb injury before encouraging weight-bearing on a possibly fractured limb. Option b is incorrect because Lifting quickly to a chair before assessment carries the same risk of converting a stable injury into a worse one. The nurse holds the patient still until injury status is clear and safe. Option c is incorrect because Moving without assessment and saving the chart for later both miss safety steps. The first priority after a fall is the patient evaluation; documentation follows after the patient has been protected and treated.

Correct Answer: Patient newly orthostatic after first diuretic dose

New orthostatic findings after a first diuretic dose mean the patient may collapse on standing. The risk is now imminent and severe, so targeted fall prevention must be added beyond the original baseline screen. Option a is incorrect because A sleeping patient with steady baseline vitals has not shifted toward higher risk. The nurse continues universal precautions, but no acute change has occurred that would alter the prevention plan in the moment. Option b is incorrect because Cane use with safe ambulation reflects steady function and a stable risk profile. The patient already had any needed targeted plan during admission, and no new cue today signals a sudden increase in risk. Option d is incorrect because Eating supper with family present provides supervision and is not a high-risk activity. The shared meal context lowers risk and does not introduce sedation, weakness, or fluid shifts that would change the plan.

Correct Answer: Reorient, place mitts, remain at bedside

Reorienting, applying soft mitts to protect the line, and staying at the bedside are least restrictive measures. They maintain freedom while preserving safety and addressing the underlying agitation through human contact. Option b is incorrect because Four-point wrist restraints jump straight to the most restrictive measure without trying gentler approaches. Such an escalation requires failed alternatives and an order, and it often worsens delirium and agitation. Option c is incorrect because Heavy benzodiazepine sedation can paradoxically increase confusion in older adults and depresses respiratory drive. Chemical restraint is not a first-line response and brings additional dangers to a fragile patient population. Option d is incorrect because A vest restraint over the chest can compress breathing and cause asphyxia, especially in confused patients. The intervention is also more restrictive than necessary when softer alternatives have not been tried first.

Correct Answer: Check skin and circulation, release periodically

Frequent assessment of skin integrity, circulation, range of motion, and toileting plus periodic release prevents pressure injury and contracture. Ongoing safety review also confirms whether restraints can finally be discontinued. Option a is incorrect because Removing restraints only at end of day misses the periodic release schedule that protects skin and joints. Long uninterrupted application risks pressure injury, contracture, and loss of dignity for the patient. Option b is incorrect because Tightening restraints to reduce wiggling raises injury risk by impairing circulation and skin integrity. Restraint snugness should always allow two-finger clearance and never compromise blood flow or comfort underneath. Option c is incorrect because Documenting once per shift fails the standard for restrained patients, who need frequent reassessment. Skin checks, neurovascular checks, and toileting offers happen on a much shorter regular interval per policy.

Correct Answer: Bed alarm, low bed, and frequent rounding

A bed alarm, low bed, and frequent rounding form a layered alternative that protects the patient without restraint. Each component reduces risk through warning, lower fall height, and timely staff response throughout the shift. Option a is incorrect because Applying a vest restraint immediately skips less restrictive alternatives and requires an order plus failed attempts. The nurse must try gentler measures first and document their lack of success. Option b is incorrect because Locking the bed wheels and walking away leaves the patient at the same level of risk. The nurse must remain attentive and use cueing or alarms; abandonment is unsafe and ethically wrong. Option d is incorrect because Heavy intramuscular sedation as a first response is chemical restraint and inappropriate without orders or attempts at alternatives. Sedation also depresses breathing and can worsen confusion, especially in older adult patients.

Correct Answer: Order requires specific clinical reason and renewal

Restraint orders must include a specific clinical reason, type, and time limit, and they must be renewed per policy. The structure protects the patient from indefinite or undocumented use of the device. Option b is incorrect because Open-ended restraint orders are not allowed under regulatory standards. Orders carry time limits and required reassessment intervals so that restraint use is reviewed and not continued without documented clinical need. Option c is incorrect because Only authorized providers can order restraints; nurses and assistive personnel cannot write the order. The nurse may apply a restraint in an immediate emergency but must obtain a provider order promptly. Option d is incorrect because Restraints may not stay on indefinitely without regular checks and renewal. Skin, circulation, range of motion, and toileting must be assessed often, and discontinuation is sought as soon as safely possible.

Correct Answer: Restraints can worsen delirium and entrapment risk

Restraints frequently worsen delirium in older adults and carry serious entrapment and asphyxia risks. The nurse must weigh those harms against the perceived benefit and use less restrictive alternatives whenever possible. Option a is incorrect because Restraints rarely produce cooperation and often increase agitation as the patient struggles. The expected outcome is more distress, not less, which is one reason alternatives are tried first in this population. Option c is incorrect because Restraints have a substantial effect on cognition by increasing confusion, fear, and agitation. The claim that they have no effect ignores a large body of evidence on delirium worsening with restraint use. Option d is incorrect because Restraints have not been shown to shorten hospital stay; they often lengthen it through complications. Pressure injury, deconditioning, and prolonged delirium all extend the time needed for safe discharge home.

Correct Answer: Sit upright at ninety degrees during meal

Sitting fully upright at ninety degrees during and after meals reduces aspiration risk after stroke. Gravity helps direct food past the trachea, and the upright posture supports safe swallowing throughout the entire meal. Option a is incorrect because Lying flat allows food and gastric contents to enter the airway and is the worst position for aspiration risk. The patient cannot generate the swallow mechanics needed to keep the airway protected. Option b is incorrect because Tilting the head back during swallowing opens the airway to food rather than directing it to the esophagus. Chin tuck or neutral head position is generally preferred to protect the airway. Option c is incorrect because Reclining at thirty degrees is not adequate for active eating. The patient needs full upright posture for the swallow mechanics to work safely; semi-recumbent angles increase the chance of aspiration.

Correct Answer: Head of bed at thirty degrees neutral

A head-of-bed elevation around thirty degrees with the neck in neutral alignment helps venous drainage from the brain. The position reduces intracranial pressure without compromising cerebral perfusion in a stable patient. Option a is incorrect because Strict flat supine with the neck flexed obstructs venous drainage and can raise intracranial pressure. Flexion or extension of the neck both compromise jugular outflow and worsen pressure inside the skull. Option b is incorrect because Sharp head turning compresses jugular veins, restricts venous drainage, and raises intracranial pressure. Neutral head and neck alignment is preferred so that drainage from the cranium is not impeded by the neck position. Option d is incorrect because Trendelenburg with feet elevated raises intracranial pressure by increasing venous return to the head. The position is harmful in head injury and should not be used unless reversing severe hypovolemic shock briefly.

Correct Answer: Reposition every two hours and document

Repositioning at least every two hours redistributes weight off bony prominences and prevents tissue ischemia. The standard interval, paired with skin checks and pressure-redistribution surfaces, is the cornerstone of pressure injury prevention. Option b is incorrect because Twelve-hour repositioning intervals leave skin under prolonged pressure and risk tissue breakdown. The cycle of ischemia and reperfusion that leads to pressure injury can begin within hours, so longer intervals are unsafe. Option c is incorrect because Waiting until the patient complains misses the early phase of pressure injury, which can be silent. Many patients cannot voice discomfort, so the nurse must turn proactively rather than reactively in this situation. Option d is incorrect because A single repositioning during a long night shift cannot prevent pressure injury in a bedbound patient. The risk grows quickly with prolonged pressure, especially over the sacrum, heels, and trochanters in immobile patients.

Correct Answer: Left lateral with right knee flexed

The left lateral or modified Sims position with the right knee flexed follows the natural curve of the sigmoid colon. The arrangement eases tubing insertion and lets gravity assist solution flow into the rectum. Option a is incorrect because Supine with knees together does not align with the sigmoid curve and makes insertion uncomfortable. The position also reduces gravity assistance and increases the risk of rectal trauma during the procedure. Option b is incorrect because Prone with arms overhead is uncomfortable and impractical for enema administration. The nurse cannot easily access the rectum or monitor the patient's comfort and reaction during the procedure in this posture. Option c is incorrect because High Fowler at ninety degrees works against gravity for fluid retention and is not the standard for enema administration. The patient may also have difficulty holding the solution upright for the necessary minutes.

Correct Answer: Keep abductor pillow between legs in bed

An abductor pillow between the legs maintains hip abduction and prevents dislocation of the new prosthesis. Posterior approach precautions also include avoiding extreme hip flexion, internal rotation, and crossing legs at any point. Option a is incorrect because Crossing the legs at the ankle or knee places the operative hip in adduction and increases dislocation risk. The patient must keep the legs apart and avoid the crossed position during the early healing weeks. Option b is incorrect because Flexing the hip past ninety degrees can dislocate the prosthesis after a posterior approach. Patients must keep hips at less than ninety degrees during sitting, transfers, and toileting to protect the joint. Option d is incorrect because Internal rotation of the operative leg places dangerous strain on the new joint and risks posterior dislocation. The leg should remain in neutral or slight external rotation to keep the prosthesis stable.