HESI RN
HESI Quizlet Fundamentals
1. What is the most important instruction for the nurse to provide a client with a new colostomy regarding stoma care?
- A. Cleanse the stoma with hydrogen peroxide and water.
- B. Apply a moisture barrier cream to the peristomal skin.
- C. Measure the stoma using a stoma guide.
- D. Use a dry gauze pad to clean the stoma.
Correct answer: C
Rationale: Measuring the stoma using a stoma guide (C) is crucial as it ensures that the appliance fits properly, which is essential for preventing skin irritation and leakage. Proper measurement helps in selecting the right size of the appliance, promoting comfort and optimal stoma care. In contrast, cleansing with hydrogen peroxide (A), applying a moisture barrier cream (B), and using a dry gauze pad (D) are important but not as critical as ensuring the correct fit of the stoma appliance.
2. When organizing home visits for the day, which older client should the home health nurse plan to visit first?
- A. A woman who takes naproxen (Naprosyn) and reports a recent onset of dark, tarry stools.
- B. A man who receives weekly injections of epoetin (Procrit) for a low serum iron level.
- C. A man with emphysema who smokes and is complaining of white patches in his mouth.
- D. A frail woman with heart failure who reported a 2-pound weight gain in the last week.
Correct answer: A
Rationale: The correct answer is A. Dark, tarry stools may indicate gastrointestinal bleeding, a potentially life-threatening condition that requires immediate attention. Visiting this client first is crucial for prompt assessment and intervention. Choices B, C, and D do not present immediate life-threatening conditions that require urgent attention compared to the potential emergency indicated by dark, tarry stools.
3. Which of the following statements is true regarding ethical principles and laws?
- A. The government enforces ethics.
- B. Laws establish standards that aid in decision-making.
- C. Ethics are highly specific.
- D. Ethical principles can serve as the foundation for laws.
Correct answer: D
Rationale: The correct answer is D. Ethical principles can influence the creation of laws but are not equivalent to laws themselves. Laws are established by governing bodies to provide a framework for society, whereas ethical principles guide individuals' moral conduct. Choice A is incorrect because governments enforce laws, not ethics. Choice B is incorrect as laws set legal standards rather than ethical ones. Choice C is incorrect because ethics are principles that guide behavior but are not necessarily highly specific.
4. A child receives a prescription for amantadine 42 mg PO BID. Amantadine is available as a 50 mg/5 mL syrup. Using a supplied calibrated measuring device, how many mL should be administered per dose? (Round to the nearest tenth.)
- A. 4.2 mL
- B. 5 mL
- C. 3.6 mL
- D. 4 mL
Correct answer: A
Rationale: To calculate the mL per dose, divide the prescribed dose (42 mg) by the concentration of the syrup (50 mg/5 mL) and then convert the result to mL. 42 mg / 50 mg = 0.84. To find the amount in mL, multiply 0.84 by 5 mL, which equals 4.2 mL. Therefore, 4.2 mL should be administered per dose.
5. The client has had a femoral-popliteal bypass surgery 6 hours ago. Which assessment provides the most accurate information about the client's postoperative status?
- A. Radial pulse.
- B. Femoral pulse.
- C. Apical pulse.
- D. Dorsalis pedis pulse.
Correct answer: D
Rationale: Assessing the dorsalis pedis pulse is crucial after a femoral-popliteal bypass surgery to determine adequate circulation distal to the surgical site. A strong dorsalis pedis pulse indicates sufficient blood flow to the foot, which is essential for monitoring postoperative status. The radial pulse (A) is not the most relevant assessment as it does not provide direct information on circulation in the lower extremities. The femoral pulse (B) may not accurately reflect circulation distal to the surgical site. The apical pulse (C) is used primarily to assess the heartbeat and cardiac function, not circulation in the lower extremities.