HESI RN
HESI Quizlet Fundamentals
1. A Native American individual presents to the clinic with complaints of frequent abdominal cramping and nausea. They state that they have chronic constipation and have not had a bowel movement in five days, despite trying several home remedies. Which intervention is most important for the healthcare provider to implement?
- A. Evaluate the stool samples for the presence of blood
- B. Assess for the presence of an impaction
- C. Determine which home remedies were used
- D. Obtain a list of prescribed medications
Correct answer: C
Rationale: It is crucial to determine which home remedies the individual has tried to avoid interactions with prescribed treatments and consider cultural practices that may influence their healthcare choices. Understanding the home remedies used can provide insights into the individual's health beliefs, preferences, and potential interactions with conventional treatments, allowing for a more holistic approach to their care.
2. An elderly client with a fractured left hip is on strict bedrest. Which nursing measure is essential to the client's nursing care?
- A. Do not massage any reddened areas.
- B. Encourage passive range of motion exercises on extremities.
- C. Position the client laterally, supine, and prone in sequence.
- D. Gently lift the client when moving into a desired position.
Correct answer: D
Rationale: The essential nursing measure for a client with a fractured left hip on strict bedrest is to gently lift the client when moving into a desired position (D). This helps to avoid shearing forces and prevents further injury. Massaging reddened areas (A) should be avoided to prevent skin damage. Active range of motion exercises (B) may be limited due to pain and muscle spasms in the affected leg. The position described in (C) is contraindicated for a client with a fractured left hip as it may cause additional harm.
3. The healthcare provider is providing passive range of motion (ROM) exercises to the hip and knee for a client who is unconscious. After supporting the client's knee with one hand, what action should the healthcare provider take next?
- A. Raise the bed to a comfortable working level.
- B. Bend the client's knee.
- C. Move the knee toward the chest as far as it will go.
- D. Cradle the client's heel.
Correct answer: D
Rationale: When providing passive ROM exercises to the hip and knee for an unconscious client, it is essential to support the joints of the knee and ankle. The next action should be to cradle the client's heel and gently move the limb in a slow, smooth, firm, but gentle manner. This helps maintain joint mobility and prevent contractures.
4. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid eating green leafy vegetables.
- B. I should wear loose-fitting clothes to avoid pressure on my legs.
- C. I should avoid prolonged sitting or standing.
- D. I should continue taking my over-the-counter herbal supplements.
Correct answer: D
Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.
5. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
- A. Report the incident to the supervisor for aseptic technique violation.
- B. Allow the completion of the procedure.
- C. Inquire about the contamination of the glove and sterile field.
- D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.
Correct answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.
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