HESI RN
HESI Quizlet Fundamentals Questions
Question 1 of 5
The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?
Correct Answer: B
Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.
Question 2 of 5
After informing an older client that an IV line needs to be inserted, the client becomes very apprehensive, loudly expressing a dislike for all healthcare providers and nurses. How should the nurse respond?
Correct Answer: C
Rationale: In this situation, the nurse should respond by calmly reassuring the client that the discomfort from the IV insertion will be temporary. By providing reassurance and addressing the client's concerns, the nurse can help reduce the client's apprehension and create a more supportive environment for the procedure.
Question 3 of 5
While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?
Correct Answer: A
Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.
Question 4 of 5
When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?
Correct Answer: C
Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.
Question 5 of 5
A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?
Correct Answer: C
Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.
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