HESI Fundamentals

HESI RN

1. A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?

A. Insert the needle at a 90-degree angle for subQ injections
B. Aspirate for blood return before injecting the medication
C. Pinch the skin before inserting the needle
D. Massage the site after administering the injection

Correct answer: C

Rationale: Pinching the skin before inserting the needle is essential in elevating the subcutaneous tissue away from the muscle. This technique ensures that the medication is administered into the correct tissue layer, promoting proper absorption and decreasing the risk of injecting into muscle tissue.

2. When caring for an older incontinent client at risk for infection, which intervention is best for the nurse to implement based on the nursing diagnosis of risk for infection?

A. Maintain standard precautions.
B. Initiate contact isolation measures.
C. Insert an indwelling urinary catheter.
D. Instruct the client in the use of adult diapers.

Correct answer: A

Rationale: The correct intervention for an older incontinent client at risk for infection is to maintain standard precautions. Standard precautions, which include proper handwashing, are essential in reducing the risk of infection transmission in vulnerable clients. Initiating contact isolation measures may not be necessary for all clients, and inserting an indwelling urinary catheter should be avoided unless medically necessary to prevent additional risks of infection. Instructing the client in the use of adult diapers is not an appropriate nursing intervention to prevent infection.

3. 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.

4. When suctioning a tracheostomy, which action is most appropriate for the nurse to take?

A. Use a sterile tube each time and suction for 30 seconds.
B. Use sterile technique and turn the suction off as the catheter is introduced.
C. Use clean technique and suction for 10 seconds.
D. Discard the catheter at the end of every shift.

Correct answer: B

Rationale: When suctioning a tracheostomy, it is crucial to use sterile technique to prevent infections. Turning off the suction as the catheter is introduced is important to avoid trauma and injury to the tracheal walls. This technique helps maintain the integrity of the tracheostomy site and ensures proper care for the patient.

5. 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?

A. Record the amount on the client's fluid output record.
B. Encourage the client to increase oral fluid intake.
C. Notify the healthcare provider of the findings.
D. Palpate the client's bladder for distention.

Correct answer: A

Rationale: The nurse should record the amount on the client's fluid output record because the 350 mL of pale yellow urine is a normal finding. This indicates appropriate urine output, so encouraging increased fluid intake or notifying the healthcare provider is not necessary at this time. Additionally, palpating the client's bladder for distention is not indicated based on the normal urine output observed.

Similar Questions

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