Questions 9

HESI RN

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HESI Fundamentals Questions

Question 1 of 5

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

Correct Answer: A

Rationale: The priority nursing action is to restore circulation by loosening the restraint (A) because blue fingers (cyanosis) indicate decreased circulation. Comparing hand color bilaterally (C) and palpating the right radial pulse (D) are important assessments to gather more information, but they do not have the priority of addressing the decreased circulation by loosening the restraint. Applying a pulse oximeter (B) is not indicated in this scenario as it measures the saturation of hemoglobin with oxygen, which is not relevant when cyanosis is related to mechanical compression from the restraints.

Question 2 of 5

A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

Correct Answer: D

Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.

Question 3 of 5

A client with a suspected kidney infection is admitted to the hospital for observation. Which action should the nurse implement to assess the client's kidney function?

Correct Answer: A

Rationale: Monitoring urine output is the most direct way to assess kidney function as it provides crucial information about the kidneys' ability to filter waste and produce urine. Changes in urine output can indicate potential issues with kidney function, such as decreased filtration or impaired excretion of waste products.

Question 4 of 5

A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?

Correct Answer: C

Rationale: Instructing the client to avoid using deodorant on the skin near the radiation site (C) is crucial to prevent skin irritation and potential adverse reactions during external radiation therapy. Sunscreen (A), heating pad (B), and dietary changes (D) are less pertinent in this situation.

Question 5 of 5

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

Correct Answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

Similar Questions

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?
When emptying 350 mL of pale yellow urine from a client's urinal, the nurse notes that this is the first time the client has voided in 4 hours. Which action should the nurse take next?
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?
A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?
While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?

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