HESI RN
HESI Fundamentals Questions
Question 1 of 5
A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
Correct Answer: C
Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.
Question 2 of 5
The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
Correct Answer: B
Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.
Question 3 of 5
A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
Correct Answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.
Question 4 of 5
When culturing a wound, the nurse should obtain the sample from which part of the wound?
Correct Answer: C
Rationale: In wound culturing, obtaining the sample from areas containing purulent or pooled exudates (Option C) is the correct approach. Purulent exudate indicates the presence of infection and provides a better sample for identifying the causative organism. This type of sample is more likely to yield accurate results for targeted treatment. Option A (The outer edges of the wound) may not provide an adequate sample of the infectious process happening within the wound. Similarly, Option B (All necrotic sections of the wound) might not offer the most relevant information for identifying the specific infectious agent causing the wound to deteriorate. Option D (Any particularly painful area of the wound) does not necessarily correlate with the presence of infection. Pain can be subjective and influenced by various factors, making it an unreliable indicator for selecting a culturing site. In an educational context, understanding the rationale behind selecting the appropriate site for wound culturing is crucial for nurses to provide evidence-based care. By choosing the area with purulent or pooled exudates, nurses can improve diagnostic accuracy and tailor treatment plans effectively based on the identified pathogens.
Question 5 of 5
What action should be taken when adding sterile liquids to a sterile field?
Correct Answer: B
Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.