HESI RN
HESI Fundamentals Quizlet Questions
Question 1 of 5
Which intervention is most important when caring for a client with a chest tube?
Correct Answer: D
Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.
Question 2 of 5
The client with chronic obstructive pulmonary disease (COPD) is being taught pursed-lip breathing by the nurse. What is the purpose of this technique?
Correct Answer: C
Rationale: Pursed-lip breathing is used to increase the amount of carbon dioxide exhaled (C) in clients with chronic obstructive pulmonary disease (COPD). By doing so, it helps prevent air trapping and enhances gas exchange, ultimately improving respiratory efficiency. While removing secretions (A), reducing air trapping (B), and slowing the respiratory rate (D) can be associated benefits, the primary goal of pursed-lip breathing is to optimize carbon dioxide elimination and enhance breathing mechanics.
Question 3 of 5
A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
Correct Answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Increasing fluid intake (A), avoiding potassium (C), and increasing protein intake (D) are not appropriate dietary instructions for heart failure management.
Question 4 of 5
A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?
Correct Answer: A
Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. Abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis but are less specific and may be seen in various other gastrointestinal conditions.
Question 5 of 5
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.