HESI RN
HESI Fundamentals
1. A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?
- A. Avoid foods high in iodine.
- B. Take your medication with meals.
- C. Monitor your weight daily.
- D. Decrease your daily fluid intake.
Correct answer: A
Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.
2. While assessing an older client's fall risk, the client reports living at home alone and never falling. Which action should the nurse take?
- A. Suggest moving to an assisted living facility
- B. Continue to obtain client data needed to complete the fall risk survey
- C. Reduce the frequency of fall risk assessments for this client
- D. Confirm that the client is safe living alone
Correct answer: B
Rationale: The correct action for the nurse to take is to continue obtaining client data to complete the fall risk survey. Even though the client reports never falling, it is essential to assess all fall risk factors comprehensively. Fall risk surveys provide valuable information on mobility, vision, medications, and other factors that can impact safety. Option A is incorrect because suggesting moving to an assisted living facility is premature without completing the fall risk assessment. Option C is incorrect as reducing the frequency of fall risk assessments could overlook potential risk factors. Option D is incorrect as the client's statement alone is not enough to confirm their safety living alone; a thorough assessment is necessary.
3. A client's subjective data includes dysuria, urgency, and urinary frequency. What action should the nurse implement next?
- A. Collect a clean-catch specimen
- B. Administer prescribed antibiotics
- C. Perform a bladder scan
- D. Increase the client's fluid intake
Correct answer: A
Rationale: The correct action for the nurse to implement next is to collect a clean-catch specimen. This is essential to diagnose the cause of the client's symptoms accurately before initiating any treatment. Administering antibiotics (Choice B) without confirming the diagnosis through a specimen collection can be inappropriate and potentially harmful. Performing a bladder scan (Choice C) may not provide the necessary information to identify the specific cause of the symptoms. Increasing the client's fluid intake (Choice D) is a general recommendation and may not address the underlying issue causing the symptoms.
4. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?
- A. Removing the empty food tray from a client with a urinary catheter.
- B. Washing and combing the hair of a client with a fractured leg in traction.
- C. Administering oral medications to a cooperative client with a wound infection.
- D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
Correct answer: D
Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.
5. A nurse is preparing to insert an indwelling urinary catheter in a female client. Which action should the nurse take to maintain sterile technique?
- A. Apply sterile gloves before inserting the catheter
- B. Use sterile gloves to insert the catheter
- C. Clean the urinary meatus with an antiseptic solution
- D. Place the drainage bag above the level of the bladder
Correct answer: B
Rationale: Using sterile gloves to insert the catheter is crucial to maintaining sterile technique. Sterile gloves help prevent the introduction of microorganisms during the insertion process. Applying sterile gloves before cleansing the perineal area (Choice A) is important but not specific to maintaining sterility during catheter insertion. Cleaning the urinary meatus with an antiseptic solution (Choice C) is a step in the catheterization process but does not solely ensure sterile technique. Placing the drainage bag above the level of the bladder (Choice D) is incorrect; the bag should be placed below the level of the bladder to facilitate urine drainage.