Hesi Fundamentals Practice Questions

Hesi Fundamentals Practice Questions *A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?* A. Tell the client that the blood pressure is high and that the reading needs to be verified by another nurse. B. Contact the health care provider to report the reading and obtain a prescription for an antihypertensive medication. C. Replace the cuff with a larger one to ensure an ample fit for the client to increase arm comfort. D. Compare the current reading with the client's previously documented blood pressure readings. - ANSWER D. Compare the current reading with the client's previously documented blood pressure readings. Rationale: Comparing this reading with previous readings will provide information about what is normal for this client; this action should be taken first. Option A might unnecessarily alarm the client. Option B is premature. Further assessment is needed to determine if the reading is abnormal for this client. Option C could falsely decrease the reading and is not the correct procedure for obtaining a blood pressure reading. *In assisting an older adult client prepare to take a tub bath, which nursing action is most important?* A. Check the bath water temperature. B. Shut the bathroom door. C. Ensure that the client has voided. D. Provide extra towels - ANSWER A. Check the bath water temperature Rationale: To prevent burns or excessive chilling, the nurse must check the bath water temperature. Options B, C, and D promote comfort and privacy and are important interventions but are of less priority than promoting safety. *The nurse who is preparing to give a 14-year-old client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the nurse take?* A. Review the chart for a signed consent for hospitalization. B. Get the health care provider's permission to give the medication. C. Do not give the medication and document the reason. D. Complete an incident report and notify the parents. - ANSWER C. Do not give the medication and document the reason. Rationale: The nurse should not give the medication and should document the reason because the client is a minor and needs a guardian's permission to receive medications. Permission to give medications is not granted by a signed hospital consent or a health care provider's permission, unless conditions are met to justify coerced treatment. Option D is not necessary unless the medication had previously been administered.