HESI RN
HESI Quizlet Fundamentals Questions
Question 1 of 5
When measuring vital signs, the healthcare provider observes that a client is using accessory neck muscles during respirations. What follow-up action should the healthcare provider take first?
Correct Answer: C
Rationale: Observing a client using accessory neck muscles during respiration indicates respiratory distress. The priority action should be to measure oxygen saturation to assess the adequacy of oxygenation. This intervention provides crucial information about the client's respiratory status and helps guide further assessment and interventions.
Question 2 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 3 of 5
A client with stage 4 lung cancer receiving in-home hospice care expresses concerns about pain while the nurse is arranging for discharge. What action should the nurse take?
Correct Answer: D
Rationale: In managing pain for a client with stage 4 lung cancer in hospice care, providing a schedule for around-the-clock prescribed analgesic use is essential. This approach ensures continuous pain control and helps prevent breakthrough pain. By having a consistent dosing schedule, the client can maintain a more stable level of pain relief, enhancing their comfort and quality of life during this critical time.
Question 4 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 5 of 5
The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
Correct Answer: D
Rationale: In the context of home administration of medications, understanding and practicing standard precautions are essential to ensure safety and prevent the spread of infections. The correct answer, option D, "Wash hands before handling the needle and syringe," demonstrates adherence to standard precautions by emphasizing proper hand hygiene before engaging in any procedure involving needles or syringes. Option A, "Remove needle before discarding used syringes," is incorrect as it does not address infection control practices. Leaving the needle exposed increases the risk of accidental needle sticks, which can lead to injury and transmission of infections. Option B, "Wear gloves to dispose of the needle and syringe," is also incorrect as gloves are not necessary for disposing of needles and syringes. Proper hand hygiene is more important in this context. Option C, "Don a face mask before administering the medication," is unnecessary for standard precautions related to needle and syringe use. Face masks are typically used in situations where there is a risk of respiratory droplet transmission, not in routine needle handling. Educationally, this question highlights the importance of understanding and applying standard precautions in healthcare settings, including home care. Emphasizing the significance of hand hygiene as a fundamental infection control measure can help prevent the spread of infections and promote safe medication administration practices.