HESI RN
HESI Quizlet Fundamentals Questions
Question 1 of 9
A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?
Correct Answer: D
Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.
Question 2 of 9
What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?
Correct Answer: C
Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.
Question 3 of 9
How should the nurse prepare the body of a deceased adult for transfer to the mortuary?
Correct Answer: B
Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.
Question 4 of 9
Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
Correct Answer: D
Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.
Question 5 of 9
Which intervention is most important to include in the plan of care for a client at high risk for the development of postoperative thrombus formation?
Correct Answer: D
Rationale: Thrombus formation is a risk for clients who are immobile postoperatively. Encouraging frequent ambulation helps to prevent stasis in the lower extremities, reducing the risk of thrombus formation. This intervention promotes circulation and prevents blood clot formation, making it the most important intervention in this situation.
Question 6 of 9
The charge nurse observes that a demographic screen has been left open on a hallway computer by a nurse who is responding to a call light while the unlicensed assistive personnel (UAP) is involved in a personal phone call. Which action should the charge nurse take first?
Correct Answer: B
Rationale: The charge nurse's first action should be to close the demographic screen on the computer to protect patient confidentiality and prevent unauthorized access to sensitive information. This immediate response addresses the breach of patient privacy and ensures that patient data is secure, setting the right priority in managing the situation.
Question 7 of 9
When caring for a client in hemorrhagic shock, how should the nurse position the client?
Correct Answer: A
Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.
Question 8 of 9
During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
Correct Answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.
Question 9 of 9
A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?
Correct Answer: A
Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.