HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 9
The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?
Correct Answer: B
Rationale: In this situation, the nurse's initial action should be to reassess the client to evaluate if restraints are still required before considering reapplication. This step ensures that the restraints are only used when absolutely necessary, promoting the client's safety and autonomy. Documentation and monitoring are essential, but reassessment of the client's condition takes precedence to provide individualized care.
Question 2 of 9
The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?
Correct Answer: B
Rationale: In this situation, the nurse's initial action should be to reassess the client to evaluate if restraints are still required before considering reapplication. This step ensures that the restraints are only used when absolutely necessary, promoting the client's safety and autonomy. Documentation and monitoring are essential, but reassessment of the client's condition takes precedence to provide individualized care.
Question 3 of 9
In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?
Correct Answer: A
Rationale: Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly.
Question 4 of 9
A client is to receive 10 mEq of KCl diluted in 250 ml of normal saline over 4 hours. At what rate should the nurse set the client's intravenous infusion pump?
Correct Answer: B
Rationale: The correct calculation involves dividing the total volume by the total time. In this case, 250 ml/4 hours = 63 ml/hour. The dose of KCl is not used in the calculation as the focus is on the rate of infusion over the specified time period.
Question 5 of 9
The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?
Correct Answer: B
Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections.
Question 6 of 9
The caregiver learns the use of a gait belt from the nurse for a woman with right-sided weakness. The caregiver demonstrates the skill. Which observation indicates that the caregiver has learned how to perform this procedure correctly?
Correct Answer: B
Rationale: Standing on the weak side of the client and holding the gait belt from the back provides better security and support during ambulation, reducing the risk of falls. This positioning allows the caregiver to offer stability and assistance without interfering with the client's movement, ensuring safe ambulation for the client with right-sided weakness.
Question 7 of 9
A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
Correct Answer: B
Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr.
Question 8 of 9
What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
Correct Answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients.
Question 9 of 9
A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?
Correct Answer: C
Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.