HESI Fundamentals Quizlet

HESI RN

1. When faced with caring for a close friend in a professional setting, which action should the staff member take first?

A. Notify the friend that all medical information will be kept confidential.
B. Explain the relationship to the charge nurse and ask for reassignment.
C. Approach the client and ask if the assignment is uncomfortable.
D. Accept the assignment but protect the client's confidentiality.

Correct answer: B

Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.

2. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?

A. Ask him to rate his pain on a scale of 1 to 10.
B. Encourage him to wait until bedtime for the pill to help him sleep.
C. Attend to an acutely ill client's needs first as the client is laughing.
D. Instruct him in the use of deep breathing exercises for pain control.

Correct answer: A

Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.

3. During a client assessment, the healthcare provider is evaluating cranial nerve function. Which assessment finding suggests that cranial nerve II is intact?

A. The client can hear a whisper from 1 to 2 feet away.
B. The client can identify an object by touch.
C. The client can shrug the shoulders against resistance.
D. The client can read a Snellen chart from 20 feet away.

Correct answer: D

Rationale: The ability to read a Snellen chart from 20 feet away indicates intact cranial nerve II (optic nerve), responsible for vision. Hearing a whisper (A) is associated with cranial nerve VIII (vestibulocochlear nerve), identifying an object by touch (B) is related to cranial nerves V (trigeminal nerve) and VII (facial nerve), and shoulder shrugging against resistance (C) is a test for cranial nerve XI (accessory nerve). Thus, the correct answer is D as it specifically tests the function of cranial nerve II.

4. The healthcare provider selects the best site for insertion of an IV catheter in the client's right arm. Which documentation should the healthcare provider use to identify placement of the IV access?

A. Left brachial vein
B. Right cephalic vein
C. Dorsal side of the right wrist
D. Right upper extremity

Correct answer: B

Rationale: The correct answer is B: Right cephalic vein. The cephalic vein is a large, superficial vein located on the radial side of the forearm, making it the preferred site for IV access. It is often the best choice for insertion of an IV catheter due to its accessibility and low risk of complications, such as infiltration. Documenting the use of the right cephalic vein for IV access is crucial for accurate and safe patient care. Choices A, C, and D are incorrect because the left brachial vein, the dorsal side of the right wrist, and the right upper extremity are not typically preferred sites for IV catheter insertion and may not provide optimal access or outcomes.

5. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?

A. Obtain a prescription from the healthcare provider regarding visitation privileges
B. Request a consultation with the ethics committee for resolution of the situation
C. Encourage the client to speak with her husband regarding his disruptive behavior
D. Communicate the client’s wishes to all members of the multidisciplinary team

Correct answer: B

Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.