HESI RN
HESI Quizlet Fundamentals
1. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?
- A. Notify the surgical team of the client’s confusion
- B. Have the client sign a new surgical consent
- C. Add the correct leg information to the consent form
- D. Inform the surgeon about the client’s concern
Correct answer: D
Rationale: In this scenario, the nurse should inform the surgeon about the client’s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.
2. A client is in the radiology department at 0900 when the prescription for levofloxacin (Levaquin) 500 mg IV q24h is scheduled to be administered. The client returns to the unit at 1300. What is the best intervention for the nurse to implement?
- A. Contact the healthcare provider and complete a medication variance form.
- B. Administer the Levaquin at 1300 and resume the 0900 schedule the next day.
- C. Notify the charge nurse and complete an incident report to explain the missed dose.
- D. Give the missed dose at 1300 and change the schedule to administer daily at 1300.
Correct answer: D
Rationale: To maintain a therapeutic level of medication, the nurse should administer the missed dose as soon as possible and adjust the administration schedule to prevent dangerously high levels of the drug in the bloodstream (D). It is important to document the reason for the delayed dose. Contacting the healthcare provider and completing a medication variance form (A) may cause unnecessary delays. Notifying the charge nurse and completing an incident report (C) should be done after addressing the immediate medication administration issue. Administering the medication at 1300 and resuming the 0900 schedule the next day (B) could lead to suboptimal therapeutic levels and potential complications.
3. A client who has a body mass index (BMI) of 30 is requesting information on the initial approach to a weight loss plan. Which action should the nurse recommend first?
- A. Plan low carbohydrate and high protein meals
- B. Engage in strenuous activity for an hour daily
- C. Keep a record of food and drinks consumed daily
- D. Participate in a group exercise class 3 times a week
Correct answer: C
Rationale: Keeping a food diary is a good first step to understand eating habits before making any dietary or activity changes.
4. 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.
5. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove needle before discarding used syringes
- B. Wear gloves to dispose of the needle and syringe
- C. Don a face mask before administering the medication
- D. Wash hands before handling the needle and syringe
Correct answer: D
Rationale: Washing hands before handling needles and syringes is a crucial aspect of standard precautions to prevent infections. This practice helps reduce the risk of transferring microorganisms from the hands to the syringes and needles, thus promoting safety during medication administration.
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