HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 5
A client has a nursing diagnosis of, 'Spiritual distress related to a loss of hope, secondary to impending death.' What intervention is best for the nurse to implement when caring for this client?
Correct Answer: B
Rationale: When a client is experiencing spiritual distress due to a loss of hope related to impending death, it is crucial for the nurse to assist and support the client in establishing short-term goals. This approach helps the client maintain hope and a sense of purpose, as achieving immediate goals can provide a sense of accomplishment and meaning. While acceptance of the final stage of life is important, helping the client set short-term goals is a more immediate and effective intervention in addressing spiritual distress.
Question 2 of 5
Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?
Correct Answer: C
Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care.
Question 3 of 5
When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?
Correct Answer: C
Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.
Question 4 of 5
When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?
Correct Answer: A
Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process.
Question 5 of 5
While the nurse is suctioning a tracheostomy tube, the client starts to cough. What is the best action for the nurse to take?
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.