HESI Quizlet Fundamentals

HESI RN

1. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?

A. Release the suction by opening the vent.
B. Continue suctioning to remove obstruction.
C. Increase the pressure.
D. Suction deeper.

Correct answer: A

Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.

2. The healthcare provider is providing wound care to a client with a stage 3 pressure ulcer that has a large amount of eschar. The wound care prescription states 'clean the wound and then apply collagenase.' Collagenase is a debriding agent. The prescription does not specify a cleaning method. Which technique should the healthcare provider use to cleanse the pressure ulcer?

A. Lightly coat the wound with povidone-iodine solution
B. Irrigate the wound with sterile normal saline
C. Flush the wound with sterile hydrogen peroxide
D. Remove the eschar with a wet-to-dry dressing

Correct answer: B

Rationale: The correct technique to cleanse a wound when the prescription does not specify a cleaning method is to irrigate the wound with sterile normal saline. Sterile normal saline is the preferred solution for wound cleaning as it is gentle and does not damage healthy tissues. It helps in removing debris and maintaining a moist environment conducive to healing. Povidone-iodine solution and hydrogen peroxide can be harsh on tissues and delay wound healing. Removing eschar with a wet-to-dry dressing is a mechanical debridement method and should not be done without proper assessment and healthcare provider's order.

3. A client is diagnosed with primary hypertension. Which assessment finding is most commonly associated with this diagnosis?

A. Headache
B. Dizziness
C. Fatigue
D. Edema

Correct answer: A

Rationale: Headache (A) is the most commonly associated symptom with primary hypertension due to increased pressure in the blood vessels, leading to headaches. While dizziness (B), fatigue (C), and edema (D) may also occur in hypertension, headache is the most frequently reported symptom among individuals with primary hypertension.

4. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?

A. Leave the body as is, no preparation needed
B. Bathe the body and place ID tags on it
C. Remove dentures before bathing the body
D. Position the body with its head down and arms folded on its chest

Correct answer: B

Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.

5. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?

A. Reassure the client that many obese individuals have concerns about sex.
B. Remind the client that sexual relationships can be maintained regardless of weight.
C. Determine the frequency of sexual intercourse.
D. Ask the client to talk about specific concerns.

Correct answer: D

Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.