HESI RN
Maternity HESI 2023 Quizlet
1. How can a nurse make a blind 8-year-old girl admitted to the hospital more comfortable?
- A. Bring familiar toys from home, such as a bear or doll.
- B. Explain the surroundings to the child.
- C. Allow the child to explore the room.
- D. Provide audio books and music.
Correct answer: A
Rationale: The correct answer is to bring familiar toys from home, such as a bear or doll. This action provides comfort and a sense of security for the child, as it allows her to have familiar objects around her in an unfamiliar environment, which can help reduce anxiety and stress during her hospital stay.
2. A male client is having abdominal pain after a left femoral angioplasty and stent, and is asking for additional pain medication for right lower quadrant pain (9/10). Two hours ago, he received hydrocodone/acetaminophen 7.5/325 mg. His vital signs are elevated from previous readings: temperature 97.8°F, heart rate 102 beats/minute, respiration 20 breaths/minute. His abdomen is swollen, the groin access site is tender, peripheral pulses are present, but the left is greater than the right. What data is needed to make this report complete?
- A. Client's lungs are clear bilaterally, and oxygen saturation is 97%.
- B. Surgeon needs to see the client immediately to evaluate the situation.
- C. Left peripheral pulses were present only by Doppler pre-procedure.
- D. Client's history includes multiple back surgeries and chronic pain.
Correct answer: B
Rationale: The correct answer is B. In this scenario, the client is experiencing abdominal pain after a left femoral angioplasty and stent, with signs of potential complications such as a swollen abdomen, tenderness at the groin access site, and unequal peripheral pulses. The client's vital signs are also elevated, indicating a worsening condition. Given these findings, the immediate evaluation by the surgeon is crucial to assess for serious complications like internal bleeding or ischemia. Choice A is incorrect as the focus should be on the urgent need for surgical evaluation rather than lung sounds and oxygen saturation. Choice C is irrelevant to the immediate management of the client's current situation. Choice D, while providing background information, is not essential for the urgent intervention required in this case.
3. The nurse on the evening shift receives report that a client is scheduled for electroconvulsive treatment (ECT) in the morning. Which intervention should the nurse implement the evening before the scheduled ECT?
- A. Hold all bedtime medication.
- B. Keep the client NPO after midnight.
- C. Implement elopement precautions.
- D. Give the client an enema at bedtime.
Correct answer: B
Rationale: Keeping the client NPO after midnight is essential to prevent aspiration during the ECT procedure. Choice A, holding all bedtime medication, is not necessary unless specified by the healthcare provider. Choice C, implementing elopement precautions, is unrelated to preparing for ECT. Choice D, giving the client an enema at bedtime, is not a standard pre-ECT intervention.
4. To prevent unnecessary hypoxia during suctioning of a tracheostomy, what must the nurse do?
- A. Apply suction for no more than 10 seconds
- B. Maintain a sterile technique
- C. Lubricate 3 to 4 inches of the catheter tip
- D. Withdraw the catheter in a circular motion
Correct answer: A
Rationale: To prevent unnecessary hypoxia during suctioning of a tracheostomy, the nurse must apply suction for no more than 10 seconds. Prolonged suctioning can lead to hypoxia by removing too much oxygen from the patient. Maintaining a sterile technique (choice B) is important to prevent infection but does not directly relate to preventing hypoxia. Lubricating the catheter tip (choice C) helps with the insertion process but does not specifically address hypoxia prevention. Withdrawing the catheter in a circular motion (choice D) is not a standard practice during tracheostomy suctioning and does not contribute to preventing hypoxia.
5. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record
- B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is a legal obligation of the examining nurse
Correct answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.