HESI RN
HESI Fundamentals
1. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?
- A. Drink clear liquids for 24 hours before the procedure
- B. Take a laxative the morning of the procedure
- C. Eat a light meal before the procedure
- D. Avoid drinking fluids for 4 hours before the procedure
Correct answer: A
Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.
2. 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.
3. 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.
4. A male client is on contact precautions due to an infected draining wound and is being discharged home. The client lives at home with his wife and their adolescent daughter. What discharge instruction should the nurse include for the client?
- A. Use disposable plates and utensils.
- B. Stay in a room with the door closed.
- C. Dispose of soiled dressings in plastic bags that are securely closed.
- D. Others who are in the same room with the client should wear a mask.
Correct answer: C
Rationale: When a client is on contact precautions due to an infected draining wound, it is important to prevent contact with wound secretions. Therefore, disposing of soiled dressings in securely closed plastic bags helps contain and prevent the spread of infectious material, reducing the risk of transmission to others in the household.
5. Warm compresses are ordered for an open wound. Which action is appropriate for the nurse?
- A. Use sterile technique when applying the compresses.
- B. Leave the compresses on the area continuously, pouring warm solution on the area when it cools down.
- C. Alternate warm compresses with cold compresses.
- D. Apply a wet dressing and cover it with a dry dressing.
Correct answer: A
Rationale: Using sterile technique when applying the compresses is crucial to prevent infection and promote wound healing. Ensuring a clean environment during wound care reduces the risk of introducing pathogens that can lead to complications. Proper infection control measures play a significant role in the healing process of open wounds. Choice B is incorrect because leaving the compresses on continuously can lead to skin damage or thermal injury. Choice C is incorrect as alternating warm compresses with cold compresses is not appropriate for an open wound. Choice D is incorrect as applying a wet dressing without following specific orders can be detrimental to wound healing.
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