Questions 9

HESI RN

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HESI Fundamentals Questions

Question 1 of 5

Earlier this morning, an elderly Hispanic female was discharged to a LTC facility. The family members are now gathered in the hallway outside her room. What is the best action?

Correct Answer: B

Rationale: In this situation, providing space and privacy for the family allows them to openly discuss their concerns regarding the client's discharge. It respects the family's need for support, communication, and involvement in the decision-making process, ultimately fostering a more effective and compassionate care environment.

Question 2 of 5

The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?

Correct Answer: C

Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.

Question 3 of 5

While changing a client's post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?

Correct Answer: C

Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.

Question 4 of 5

During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

Correct Answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

Question 5 of 5

The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?

Correct Answer: C

Rationale: Suctioning the patient in a supine position and pulling the bed sheets tightly across their feet can lead to foot drop, which is harmful for a patient with right-sided hemiplegia. This action can exacerbate muscle weakness and impair circulation in the affected limb. It is crucial to avoid actions that may compromise the patient's safety and well-being, such as causing foot drop in this scenario.

Similar Questions

The patient had a CVA and developed right-sided hemiplegia. Which action is least appropriate for the nurse to take?
A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?
When culturing a wound, the nurse should obtain the sample from which part of the wound?
During a clinic visit, the mother of a 7-year-old reports to the nurse that her child is often awake until midnight playing and is then very difficult to awaken in the morning for school. Which assessment data should the nurse obtain in response to the mother's report?
At 0100 on a male client's second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?

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