HESI RN
HESI Fundamentals
1. A client with a history of heart failure is admitted with a diagnosis of pulmonary edema. Which intervention should the nurse implement first?
- A. Administer oxygen via non-rebreather mask.
- B. Administer furosemide (Lasix) IV push.
- C. Insert a Foley catheter to monitor urine output.
- D. Position the client in a high Fowler's position.
Correct answer: A
Rationale: Administering oxygen via a non-rebreather mask is the priority intervention for a client with pulmonary edema to improve oxygenation and address respiratory distress. Adequate oxygenation is essential to support vital organ function. Administering furosemide intravenously, inserting a Foley catheter to monitor urine output, and positioning the client in a high Fowler's position are important interventions but are secondary to ensuring optimal oxygenation in this client with pulmonary edema.
2. While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?
- A. Encourage the client to see the clinic's grief counselor.
- B. Determine if the client has a family history of suicide attempts.
- C. Inquire about whether the life partner had AIDS.
- D. Consult with the healthcare provider about the client's need for antidepressant medications.
Correct answer: A
Rationale: The client is exhibiting symptoms of normal grief, such as flat affect, withdrawal, and sleep disturbances, following the recent death of his life partner. It is crucial for the nurse to encourage the client to see the clinic's grief counselor. Grief counseling can provide the client with appropriate support and coping strategies during this grieving process, helping him navigate through his loss and emotions effectively.
3. Urinary catheterization is prescribed for a postoperative female client who has been unable to void for 8 hours. The nurse inserts the catheter, but no urine is seen in the tubing. Which action will the nurse take next?
- A. Clamp the catheter and recheck it in 60 minutes.
- B. Pull the catheter back 3 inches and redirect it upward.
- C. Leave the catheter in place and reattempt with another catheter.
- D. Notify the healthcare provider of a possible obstruction.
Correct answer: C
Rationale: In this scenario, if no urine is seen in the tubing after inserting the catheter, it is likely that the catheter is in the vagina rather than the bladder. Leaving the first catheter in place will help locate the meatus more easily when attempting the second catheterization. This approach ensures correct placement of the catheter in the bladder and minimizes the risk of causing unnecessary discomfort or trauma to the patient.
4. While changing a client’s post-operative dressing, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Given a positive MRSA result, what is the most important action for the nurse to take?
- A. Force oral fluids
- B. Request a nutrition consult
- C. Initiate contact precautions
- D. Limit visitors to immediate family only
Correct answer: C
Rationale: Initiating contact precautions is crucial in this situation to prevent the spread of MRSA infection. MRSA is a highly contagious bacterium that can spread through direct contact with an infected wound or by touching contaminated surfaces. By implementing contact precautions, the nurse can help contain the infection and protect other patients, healthcare workers, and visitors from being exposed to MRSA.
5. What type of technique should the nurse observe when preparing to insert an indwelling catheter?
- A. Clean technique.
- B. Medical Asepsis.
- C. Isolation Protocol.
- D. Sterile Technique.
Correct answer: D
Rationale: When inserting an indwelling catheter, the nurse must observe sterile technique to minimize the risk of infections. Sterile technique involves using sterile equipment and maintaining a sterile field to prevent introducing pathogens into the urinary tract.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $69.99
HESI RN Premium
$149.99/ 90 days
- 50,000 Questions with answers
- All HESI courses Coverage
- 30 days access @ $149.99