HESI RN
HESI Fundamentals Quizlet
1. During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?
- A. Between the vaginal orifice and the anus.
- B. Between the clitoris and the vaginal orifice.
- C. Just above the clitoris.
- D. Within the vaginal canal.
Correct answer: B
Rationale: The correct location of the urethral meatus in females is between the clitoris and the vaginal orifice. When performing a urethral catheterization, it is crucial to identify this anatomical landmark for correct insertion of the catheter. Choice A is incorrect as the urethral meatus is not located between the vaginal orifice and the anus. Choice C is incorrect as the urethral meatus is not located just above the clitoris. Choice D is incorrect as the urethral meatus is not within the vaginal canal.
2. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?
- A. Amount of support provided by family members
- B. Measurement of pain using a scale of 0 to 10
- C. The ability to perform ADLs
- D. Nonverbal behaviors exhibited when pain occurs
Correct answer: C
Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs. While family support, pain measurement, and nonverbal behaviors are important aspects to consider in caring for a client with chronic pain, the ability to perform ADLs directly reflects the client's independence and quality of life, making it the most crucial information to obtain.
3. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?
- A. Surgery removes the disk and is the only treatment that can totally resolve the pain
- B. The medication regimen you previously used should be re-evaluated for dose adjustment
- C. Massage and hot pack treatments are less invasive and can provide temporary relief
- D. Acupuncture is a complementary therapy that is often effective for management of pain
Correct answer: D
Rationale: Acknowledging the effectiveness of acupuncture is important, as the client has reported its success in managing her pain previously.
4. Before administering a client's medication, the nurse assesses a change in the client's condition and decides to withhold the medication until consulting with the healthcare provider. After consultation with the healthcare provider, the dose of the medication is changed, and the nurse administers the newly prescribed dose an hour later than the originally scheduled time. What action should the nurse take in response to this situation?
- A. Notify the charge nurse that a medication error occurred.
- B. Submit a medication variance report to the supervisor.
- C. Document the events that occurred in the nurse's notes.
- D. Discard the original medication administration record.
Correct answer: C
Rationale: In this scenario, the nurse acted appropriately by withholding the medication, consulting with the healthcare provider, and administering the newly prescribed dose, albeit with a delay. The correct course of action for the nurse is to document all these events in the nurse's notes. Documenting the sequence of actions taken is crucial for maintaining an accurate record of the client's care, ensuring transparency, and providing essential information for future reference and continuity of care. Notifying the charge nurse or submitting a medication variance report may not be necessary as the situation was managed appropriately, and discarding the original medication administration record is not recommended as it is part of the client's medical record and should be kept for documentation purposes.
5. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?
- A. Confirm the finding by further assessing the client for jugular vein distention.
- B. Offer the client high-protein snacks between regularly scheduled mealtimes.
- C. Continue the planned nursing interventions to restore the client's fluid volume.
- D. Change the plan of care to include interventions for impaired skin integrity.
Correct answer: C
Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.
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