HESI RN
HESI Fundamentals
1. A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?
- A. Avoid foods high in iodine.
- B. Take your medication with meals.
- C. Monitor your weight daily.
- D. Decrease your daily fluid intake.
Correct answer: A
Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.
2. The healthcare provider obtains a BP reading of 100/88 in the right arm of a client whose blood pressure is typically 120/60 in the same arm. What action should the healthcare provider implement first?
- A. Use an electronic sphygmomanometer to take the BP every 30 minutes.
- B. Retake the blood pressure in the same arm, deflating the cuff slowly.
- C. Ask another healthcare provider to recheck the blood pressure to compare results.
- D. Obtain another blood pressure cuff and retake the blood pressure.
Correct answer: B
Rationale: The healthcare provider should first retake the blood pressure in the right arm, deflating the cuff slowly, because a low systolic and high diastolic blood pressure measurement is often the result of deflating the cuff too rapidly. Taking the BP in the same arm ensures consistency and accuracy of the measurement.
3. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?
- A. Removing the empty food tray from a client with a urinary catheter.
- B. Washing and combing the hair of a client with a fractured leg in traction.
- C. Administering oral medications to a cooperative client with a wound infection.
- D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
Correct answer: D
Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.
4. 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.
5. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
- A. Use disposable plates and utensils.
- B. Stay in a room with the door closed.
- C. Dispose of soiled dressings in plastic bags that are securely closed.
- D. Others who are in the same room with the client should wear a mask.
Correct answer: C
Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.
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