HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 5
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 2 of 5
A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
Correct Answer: D
Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. This step is essential for appropriate decision-making and planning further care.
Question 3 of 5
The healthcare provider assesses a 2-year-old who is admitted for dehydration and finds that the peripheral IV rate by gravity has slowed, even though the venous access site is healthy. What should the healthcare provider do next?
Correct Answer: B
Rationale: In this scenario, the correct answer is B) Check for kinks in the tubing and raise the IV pole. This is the most appropriate action because a slowed IV rate can often be attributed to a kink in the tubing, which obstructs the flow of fluids. By checking for kinks and raising the IV pole, gravity can help facilitate the flow of the intravenous solution, thereby correcting the issue. Option A) Apply a warm compress proximal to the site is incorrect because this intervention is more suitable for addressing phlebitis or inflammation at the site, not a slowed IV rate due to kinks in the tubing. Option C) Adjust the tape that stabilizes the needle is also incorrect as stabilizing the needle does not address the issue of a slowed IV rate, which is likely due to an obstruction in the tubing. Option D) Flush with normal saline and recount the drop rate is unnecessary at this point as the issue is most likely related to mechanical factors in the IV tubing rather than a blockage at the venous access site. Educationally, this question highlights the importance of troubleshooting common issues related to IV administration in pediatric patients. It underscores the significance of understanding how to assess and address complications that may arise during IV therapy to ensure safe and effective patient care.
Question 4 of 5
A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
Correct Answer: C
Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric-mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care.
Question 5 of 5
A staff member is assigned to care for a close friend in the hospital setting. Which action should the staff member take first when given the assignment?
Correct Answer: B
Rationale: The correct answer to the question is B) Explain the relationship to the charge nurse and ask for reassignment. This action should be taken first because it upholds professional boundaries and ethics in nursing practice. Choosing option A would not be appropriate as informing the friend about confidentiality is important but should not be the first step in this situation. Option C places the burden on the client to address the discomfort, which is not professional. Option D does not address the potential conflict of interest that may arise when caring for a close friend. In the educational context, this question highlights the importance of maintaining professional boundaries in nursing practice. Nurses must prioritize the well-being and best interests of their patients above personal relationships. By seeking reassignment when faced with a potential conflict of interest, nurses uphold ethical standards and ensure quality care delivery.