HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 5
A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
Correct Answer: B
Rationale: In the context of nursing care for a Jehovah's Witness client, the correct concern for planning care is option B: Blood transfusions are forbidden. This is because Jehovah's Witnesses refuse blood transfusions based on their religious beliefs. It is crucial for nurses to respect and adhere to the client's wishes regarding blood products to provide culturally competent care. Option A, autopsy of the body being prohibited, is not a primary concern in immediate care planning for a Jehovah's Witness client. While this is a belief in the faith, it does not have the same urgent implications as the prohibition of blood transfusions. Option C, alcohol use in any form is not allowed, is not directly related to the urgent care planning needs of a Jehovah's Witness client and is not a significant concern compared to the prohibition of blood transfusions. Option D, a vegetarian diet must be followed, is also not as critical as the prohibition of blood transfusions in the context of immediate care planning for a Jehovah's Witness client. While dietary considerations are important, they do not pose the same level of immediate risk as the refusal of blood transfusions. Educationally, this question highlights the importance of understanding and respecting diverse cultural and religious beliefs in nursing practice. Nurses must be knowledgeable about different faith traditions to provide individualized, respectful care that aligns with the client's values and beliefs.
Question 2 of 5
Which intervention is most important when caring for a client with a chest tube?
Correct Answer: D
Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.
Question 3 of 5
During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?
Correct Answer: D
Rationale: In assessing cranial nerve function, specifically cranial nerve II (optic nerve), the correct answer is D) The client can read a Snellen chart from 20 feet away. This finding indicates intact visual acuity, which is directly related to the function of cranial nerve II. Option A) The client can hear a whisper from 1 to 2 feet away, pertains to cranial nerve VIII (vestibulocochlear nerve), responsible for hearing and balance. Option B) The client can identify an object by touch, refers to cranial nerve V (trigeminal nerve), involved in facial sensation and chewing. Option C) The client can shrug the shoulders against resistance, relates to cranial nerve XI (accessory nerve), responsible for neck and shoulder movements. In an educational context, understanding cranial nerve function is crucial for nurses to perform comprehensive assessments and detect neurological abnormalities. Knowing the specific functions of each cranial nerve aids in accurately identifying issues and providing appropriate care to patients. It is essential for nurses to be able to differentiate assessment findings related to various cranial nerves to ensure effective patient care and outcomes.
Question 4 of 5
The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?
Correct Answer: C
Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A), reducing air trapping (B), and slowing the respiratory rate (D) can be associated benefits, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics.
Question 5 of 5
A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
Correct Answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Increasing fluid intake (A), avoiding potassium (C), and increasing protein intake (D) are not appropriate dietary instructions for heart failure management.