HESI Fundamentals

HESI RN

1. What action should be taken when adding sterile liquids to a sterile field?

A. Use an expired sterile liquid if the bottle is sealed and unopened.
B. Consider the sterile field contaminated if it becomes wet during the procedure.
C. Remove the container cap and place it with the inside facing up on the sterile field.
D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.

Correct answer: B

Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.

2. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?

A. Check the client's carotid pulse.
B. Encourage the client to get to the toilet.
C. In a loud voice, call for help.
D. Gently lower the client to the floor.

Correct answer: D

Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.

3. 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?

A. Loosen the right wrist restraint.
B. Apply a pulse oximeter to the right hand.
C. Compare hand color bilaterally.
D. Palpate the right radial pulse.

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.

4. When assessing a male client, the nurse finds that he is fatigued and experiencing muscle weakness, leg cramps, and cardiac dysrhythmias. Based on these findings, the nurse plans to check the client’s laboratory values to validate the existence of which condition?

A. Hyperphosphatemia
B. Hypocalcemia
C. Hypermagnesemia
D. Hypokalemia

Correct answer: D

Rationale: The symptoms of fatigue, muscle weakness, leg cramps, and cardiac dysrhythmias are classic manifestations of hypokalemia. Potassium plays a vital role in muscle function and cardiac conduction, so a deficiency can lead to these symptoms. Checking the client’s laboratory values for potassium levels will help confirm the presence of hypokalemia.

5. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?

A. Complete blood count (CBC)
B. Serum potassium level
C. Liver function tests (LFTs)
D. Serum cholesterol level

Correct answer: C

Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.