HESI RN
HESI Quizlet Fundamentals
1. 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.
2. After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?
- A. Is voiding normally.
- B. Has urinary retention.
- C. Has developed renal failure.
- D. Needs an indwelling catheter.
Correct answer: B
Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.
3. Sildenafil (Viagra) is prescribed to treat a client with erectile dysfunction. A nurse reviews the client's medical record and would question the prescription if which of the following is noted in the client's history?
- A. Neuralgia
- B. Insomnia
- C. Use of nitroglycerin
- D. Use of multivitamins
Correct answer: C
Rationale: The correct answer is C. Sildenafil (Viagra) enhances the vasodilating effect of nitric oxide and is contraindicated with the concurrent use of organic nitrates and nitroglycerin. Using nitroglycerin together with Viagra can lead to severe hypotension and cardiovascular collapse, making it unsafe to combine both medications.
4. The nurse is completing a client's preoperative routine and finds that the operative permit is not signed. The client begins to ask more questions about the surgical procedure. Which action should the nurse take next?
- A. Witness the client's signature on the permit.
- B. Answer the client's questions about the surgery.
- C. Inform the surgeon that the operative permit is not signed and the client has questions about the surgery.
- D. Reassure the client that the surgeon will answer any questions before the anesthesia is administered.
Correct answer: C
Rationale: The nurse should inform the surgeon immediately that the operative permit is not signed and that the client has questions about the surgery. It is crucial for the surgeon to be aware of the situation so they can address the client's concerns, explain the procedure, and obtain the necessary signed permit before proceeding with the surgery. This ensures informed consent and compliance with preoperative protocols.
5. What is the most important assessment for a nurse to conduct on a child diagnosed with intussusception?
- A. Monitor for signs of infection.
- B. Measure abdominal girth and monitor for pain.
- C. Check for bowel movement and changes in stool.
- D. Assess hydration status and monitor urine output.
Correct answer: C
Rationale: The correct answer is C: 'Check for bowel movement and changes in stool.' Intussusception can cause obstruction in the bowel, leading to symptoms like abdominal pain, vomiting, and 'currant jelly' stools. Monitoring for changes in bowel movement, especially the passage of 'currant jelly' stools, is crucial for early detection of worsening conditions. Choices A, B, and D are important assessments in pediatric care but are not as specific or crucial as checking for changes in bowel movement in a child diagnosed with intussusception.