HESI RN
HESI Fundamentals Quizlet
1. A community hospital is opening a mental health services department. Which document should the nurse use to develop the unit's nursing guidelines?
- A. Americans with Disabilities Act of 1990
- B. ANA Code of Ethics with Interpretative Statements
- C. ANA's Scope and Standards of Nursing Practice
- D. Patient's Bill of Rights of 1990
Correct answer: C
Rationale: The ANA's Scope and Standards of Nursing Practice are essential guidelines for nursing practice in various specialties, including mental health. The document outlines the expectations and responsibilities of nurses in providing high-quality care within their specific practice areas. In the context of opening a mental health services department, using the Scope and Standards specific to psychiatric–mental health nursing would ensure that the unit's nursing guidelines align with best practices and professional standards in mental health care. Choices A, B, and D are not focused on providing specific guidelines for nursing practice in a mental health services department, making them incorrect options.
2. An RN is providing education to the family of a client diagnosed with schizophrenia who is being treated with clozapine (Clozaril). The RN should instruct the family to report which symptom immediately?
- A. Sore throat
- B. Weight loss
- C. Constipation
- D. Lightheadedness
Correct answer: A
Rationale: The correct answer is A: Sore throat. Clozapine can lead to agranulocytosis, a condition characterized by a significant decrease in white blood cells. A sore throat can be an early sign of agranulocytosis, a potentially life-threatening adverse effect of clozapine. The family should report this symptom immediately to the healthcare provider for further evaluation and management. Choices B, C, and D are incorrect because weight loss, constipation, and lightheadedness are not typically associated with the serious adverse effect of agranulocytosis related to clozapine therapy.
3. The nurse is preparing to administer an IM injection to a 6-month-old child. Which injection site is best for the nurse to use?
- A. Vastus lateralis
- B. Deltoid
- C. Ventrogluteal
- D. Dorsogluteal
Correct answer: A
Rationale: The vastus lateralis is the preferred site for IM injections in infants due to muscle development. In infants under 1 year old, the vastus lateralis muscle in the thigh is often used for IM injections due to its size and development. The deltoid muscle is typically used for adults, and the ventrogluteal and dorsogluteal sites are more commonly used for older children and adults. Therefore, the best choice for administering an IM injection to a 6-month-old child is the vastus lateralis.
4. While assessing a client who is admitted with heart failure and pulmonary edema, the nurse identifies dependent peripheral edema, an irregular heart rate, and a persistent cough that produces pink blood-tinged sputum. After initiating continuous telemetry and positioning the client, which intervention should the nurse implement?
- A. Administer prescribed diuretics
- B. Prepare for intubation
- C. Notify the healthcare provider immediately
- D. Obtain sputum sample
Correct answer: D
Rationale: The client's cough producing pink, frothy sputum is indicative of pulmonary edema, which needs immediate treatment. Obtaining a sputum sample helps identify any infection that may be contributing to the pulmonary issues. Administering diuretics is essential in managing pulmonary edema but obtaining a sputum sample should take priority. Intubation may be necessary in severe cases but is not the initial intervention. Notifying the healthcare provider is important, but immediate action to diagnose and treat the condition is crucial.
5. The practical nurse is reinforcing information about Lyme disease prevention with a client who is preparing for a camping trip with family. Which statement by the client informs the nurse that the client understands the instruction?
- A. I'll make sure my son wears dark clothing on his hike.
- B. I'll get a prescription for amoxicillin to take with us.
- C. We should all get the Lyme disease vaccine before our trip.
- D. We will wear long pants and long-sleeved shirts in the woods.
Correct answer: D
Rationale: The correct answer is D. Wearing long pants and long-sleeved shirts is an effective preventive measure against tick bites, which reduces the risk of contracting Lyme disease. This attire helps to minimize skin exposure to ticks, thereby decreasing the chances of a tick attaching and transmitting the disease-causing bacteria.