HESI RN
HESI Fundamentals Quizlet
1. The nurse is preparing to administer 2 units of packed red blood cells (PRBCs) to a client. Which action should the nurse implement to ensure the client’s safety?
- A. Obtain informed consent from the client for the PRBC transfusion
- B. Review the client’s medical history for a history of transfusion reactions
- C. Assess the client’s baseline vital signs before starting the transfusion
- D. Verify the blood type and crossmatch with another licensed nurse
Correct answer: D
Rationale: Verifying the blood type and crossmatch with another licensed nurse is crucial to prevent transfusion reactions and ensure the client's safety. This step helps confirm that the correct blood type is being transfused to the client, reducing the risk of adverse reactions and promoting safe care. Obtaining informed consent (Choice A) is important but not directly related to ensuring the safety of the transfusion. Reviewing the client's medical history for transfusion reactions (Choice B) is relevant but not as crucial as verifying the blood type and crossmatching. Assessing baseline vital signs (Choice C) is a routine practice before transfusion but ensuring the correct blood type is a higher priority.
2. A client is to receive cimetidine (Tagamet) 300 mg q6h IVP. The preparation arrives from the pharmacy diluted in 50 ml of 0.9% NaCl. The nurse plans to administer the IVPB dose over 20 minutes. For how many ml/hr should the infusion pump be set to deliver the secondary infusion?
- A. 75 ml/hr
- B. 150 ml/hr
- C. 225 ml/hr
- D. 300 ml/hr
Correct answer: B
Rationale: To calculate the infusion rate, set up a ratio proportion problem: 50 ml/20 min = x ml/60 min. Cross multiply to solve: 50 × 60 / 20 = 150 ml/hr. Therefore, the infusion pump should be set to deliver the secondary infusion at a rate of 150 ml/hr. Option A, 75 ml/hr, is incorrect because it does not account for the correct calculation. Option C, 225 ml/hr, is incorrect as it is too high a rate based on the calculation. Option D, 300 ml/hr, is also incorrect as it does not align with the correct calculation for the infusion rate.
3. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
- A. Maintain the client in a lateral position using protective wrist and vest restraints.
- B. Position the client prone with a small pillow below the diaphragm.
- C. Raise the head and knee gatch when lying in a supine position.
- D. Transfer the client to a wheelchair close to the nursing station for observation.
Correct answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.
4. A client's blood pressure reading is 156/94 mm Hg. Which action should the nurse take first?
- A. Inform the client that the blood pressure is high and that the reading needs to be verified by another nurse.
- B. Contact the healthcare provider to report the reading and obtain a prescription for an antihypertensive medication.
- C. Replace the cuff with a larger one to ensure a proper fit for the client and increase arm comfort.
- D. Compare the current reading with the client's previously documented blood pressure readings.
Correct answer: D
Rationale: The correct action for the nurse to take first in this situation is to compare the current blood pressure reading with the client's previously documented readings. This comparison will provide valuable information about what is normal for this specific client, helping to determine if the current reading represents a significant change or if it falls within the client's usual range. By reviewing the client's past readings, the nurse can assess trends, variations, and if the current reading is an isolated high value or part of a pattern, guiding appropriate decision-making. Informing the client about the high reading (Choice A) or contacting the healthcare provider for medication (Choice B) should come after assessing the client's history. Replacing the cuff (Choice C) is not necessary at this point and does not address the immediate need to compare the readings for appropriate intervention.
5. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
- A. Remove identifying information of the clients who participated
- B. Recall that authored content may be legally discoverable
- C. Share material from credible, peer-reviewed sources only
- D. Respect all copyright laws when adding website content
Correct answer: A
Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.
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