HESI RN
HESI Fundamentals
1. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:
- A. Cuff blood pressure.
- B. Arterial pressure.
- C. Pulmonary artery pressure.
- D. Central venous pressure.
Correct answer: D
Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.
2. A client with a diagnosis of renal failure is receiving hemodialysis. Which assessment finding should the nurse report to the healthcare provider immediately?
- A. The client's blood pressure is 130/80 mm Hg.
- B. The client gains 1 kg in 24 hours.
- C. The client's potassium level is 5.5 mEq/L.
- D. The client's weight decreases by 0.5 kg in 24 hours.
Correct answer: C
Rationale: A potassium level of 5.5 mEq/L (C) is elevated and concerning in a client with renal failure receiving hemodialysis, as it can lead to life-threatening cardiac arrhythmias. Monitoring blood pressure (A), weight gain (B), and weight loss (D) are essential in clients on hemodialysis, but an elevated potassium level poses an immediate risk that requires prompt intervention.
3. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
- A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
- B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
- C. Assist the client to a standing position by gently lifting upward underneath the axillae.
- D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Correct answer: B
Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.
4. When culturing a wound, the nurse should obtain the sample from which part of the wound?
- A. The outer edges of the wound.
- B. All necrotic sections of the wound.
- C. Areas containing purulent or pooled exudates.
- D. Any particularly painful area of the wound.
Correct answer: C
Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.
5. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
- A. Hydrogel dressing.
- B. Exudate absorber.
- C. Wet-to-moist dressing.
- D. Transparent adhesive film.
Correct answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.
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