HESI RN
HESI Fundamentals Quizlet
1. The healthcare provider identifies a potential for infection in a client with partial-thickness (second-degree) and full-thickness (third-degree) burns. What intervention has the highest priority in decreasing the client's risk of infection?
- A. Administration of plasma expanders
- B. Use of careful handwashing technique
- C. Application of a topical antibacterial cream
- D. Limiting visitors to the client with burns
Correct answer: B
Rationale: Proper handwashing technique is crucial in preventing the transmission of infections, especially in clients with burns where the risk of infection is high. It is the most effective intervention to reduce the risk of contamination and promote healing in these clients. While plasma expanders, topical antibacterial creams, and visitor restrictions are important considerations in burn care, meticulous hand hygiene takes precedence in preventing infections. Handwashing helps remove pathogens that could lead to infections, making it essential in the care of clients with burns.
2. During the digital removal of a fecal impaction, the nurse should stop the procedure and take corrective action if which client reaction is noted?
- A. Temperature increases from 98.8° to 99.0° F.
- B. Pulse rate decreases from 78 to 52 beats/min.
- C. Respiratory rate increases from 16 to 24 breaths/min.
- D. Blood pressure increases from 110/84 to 118/88 mmHg.
Correct answer: B
Rationale: During digital removal of a fecal impaction, a vagal response can occur due to stimulation of the anal sphincter. If the client experiences bradycardia (pulse rate decreases), the nurse should stop the procedure immediately and take corrective action to prevent any complications. Choices A, C, and D are incorrect because they do not indicate a vagal response, which is the expected adverse reaction during this procedure.
3. When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?
- A. Place a sterile drape under the client's buttocks.
- B. Instruct the client to inhale and then exhale slowly.
- C. Discard the gloves and apply new sterile gloves.
- D. Apply a sterile lubricant to the end of the catheter.
Correct answer: D
Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.
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 community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretative Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct answer: C
Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.
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