HESI RN
HESI Quizlet Fundamentals Questions
Question 1 of 5
The client has removed the covering from an ice pack applied to his knee. What action should the nurse take first?
Correct Answer: A
Rationale: The primary action for the nurse is to assess the skin under the ice pack to check for any potential thermal injury. This assessment is crucial to ensure the client's safety. Once the skin assessment is done and no harm is found, the nurse can proceed with other necessary actions such as providing instructions to the client or replacing the covering with fresh ice.
Question 2 of 5
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 5
A client with a history of myocardial infarction (MI) is admitted with chest pain. Which laboratory test should the nurse expect to be ordered to determine if the client is experiencing another MI?
Correct Answer: A
Rationale: Troponin is the most specific and sensitive laboratory test for detecting myocardial infarction (MI). It is released when there is damage to the heart muscle, making it a valuable marker for diagnosing another MI. Myoglobin and CK-MB can also be elevated in MI, but troponin is preferred due to its higher specificity. C-reactive protein is a marker of inflammation and not specific to MI.
Question 4 of 5
A client with a history of diabetes mellitus is admitted with a blood glucose level of 600 mg/dL. What type of insulin should the nurse prepare to administer to this client?
Correct Answer: A
Rationale: In a client with a blood glucose level of 600 mg/dL, which indicates severe hyperglycemia or diabetic ketoacidosis, the nurse should prepare to administer regular insulin (A). Regular insulin has a rapid onset of action and is the preferred choice for immediate correction of high blood glucose levels. NPH insulin (B), lispro insulin (C), and glargine insulin (D) are not suitable for the rapid correction of severe hyperglycemia.
Question 5 of 5
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.