HESI RN
HESI Fundamentals Quizlet
1. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs and then get fitted for a filter mask before providing personal care.
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client.
- D. Before changing assignments, determine which staff members have fitted particulate filter masks.
Correct answer: C
Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. Choice A is incorrect because the UAP does not need to get fitted for a particulate filter mask before providing care in this situation. Choice B is incorrect as fitting for a particulate filter mask is not necessary for droplet precautions. Choice D is also incorrect because determining which staff members have fitted particulate filter masks is not relevant to the UAP's situation with the client on droplet precautions. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.
2. A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?
- A. Autopsy of the body is prohibited.
- B. Blood transfusions are forbidden.
- C. Alcohol use in any form is not allowed.
- D. A vegetarian diet must be followed.
Correct answer: B
Rationale: The correct answer is B. In the Jehovah's Witness religion, blood transfusions are forbidden due to their beliefs. Autopsy prohibition is in Judaism, while alcohol and drug use is not allowed in Buddhism. While some sects are vegetarian, the critical concern in nursing care for Jehovah's Witnesses is respecting their prohibition of blood transfusions.
3. The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?
- A. Dependent rubor.
- B. Absence of hair on the lower legs.
- C. Shiny, thin skin on the legs.
- D. Pain in the legs when walking.
Correct answer: D
Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.
4. A male client with acquired immunodeficiency syndrome (AIDS) develops cryptococcal meningitis and tells the nurse he does not want to be resuscitated if his breathing stops. What action should the nurse implement?
- A. Document the client's request in the medical record.
- B. Ask the client if this decision has been discussed with his healthcare provider.
- C. Inform the client that a written, notarized advance directive is required to withhold resuscitation efforts.
- D. Advise the client to designate a person to make healthcare decisions when the client is unable to do so.
Correct answer: B
Rationale: When a client expresses the desire to not be resuscitated, it is essential to inquire if this decision has been discussed with their healthcare provider. This is important to ensure that the client's wishes are appropriately documented and legally binding through the healthcare provider's guidance. It is crucial that healthcare decisions, especially those involving life-saving measures, are well-communicated and documented to respect the client's autonomy and ensure their wishes are honored. Option A is not the best action as it does not address the need to verify discussion with the healthcare provider. Option C is incorrect as it overemphasizes the need for a notarized advance directive, which may not be immediately feasible or necessary in this urgent situation. Option D is not the most appropriate action at this time since the immediate focus should be on clarifying if the decision has been communicated with the healthcare provider.
5. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the healthcare professional could lose the case.
- B. The lawsuit may be settled out of court, but the healthcare professional's license is likely to be revoked.
- C. There will be no judgment against the healthcare professional, whose actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Correct answer: C
Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.
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