HESI RN
HESI Quizlet Fundamentals
1. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
- A. Report the incident to the supervisor for aseptic technique violation.
- B. Allow the completion of the procedure.
- C. Inquire about the contamination of the glove and sterile field.
- D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.
Correct answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.
2. When assessing a pregnant patient with eclampsia who is receiving IV magnesium sulfate, which finding should the nurse report to the health care provider immediately?
- A. The bibasilar breath sounds are decreased.
- B. The patellar and triceps reflexes are absent.
- C. The patient has been sleeping most of the day.
- D. The patient reports feeling 'sick to my stomach.'
Correct answer: B
Rationale: The correct answer is B because the absence of patellar and triceps reflexes indicates potential magnesium toxicity, requiring immediate intervention. Nausea and lethargy are common side effects of elevated magnesium levels and should be reported, but they are not as critical as the loss of deep tendon reflexes. Decreased breath sounds suggest the need for coughing and deep breathing to prevent atelectasis, which is important but not as urgent as addressing magnesium toxicity.
3. A client is taking cetirizine hydrochloride (Zyrtec). The nurse checks for which of the following side effects of this medication?
- A. Diarrhea
- B. Excitability
- C. Drowsiness
- D. Excess salivation
Correct answer: C
Rationale: Cetirizine hydrochloride (Zyrtec) is known to commonly cause drowsiness or sedation as a side effect. Therefore, the nurse should monitor the client for signs of drowsiness when administering this medication. Choice A, Diarrhea, is not a common side effect of cetirizine. Choice B, Excitability, is not a typical side effect of this antihistamine; instead, it tends to cause drowsiness. Choice D, Excess salivation, is not associated with cetirizine use.
4. The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother?
- A. Give small amounts of baby food with each feeding.
- B. Thicken formula with cereal for each feeding.
- C. Dilute the child's formula with equal parts of water.
- D. Offer 10% dextrose in water between most feedings.
Correct answer: B
Rationale: Thickening formula with cereal is a recommended intervention for infants with gastroesophageal reflux disease (GERD) to help reduce vomiting and increase caloric intake. This modification can help the infant keep the food down better, reducing reflux symptoms while providing adequate nutrition. Giving small amounts of baby food with each feeding (Choice A) is not recommended for a 5-month-old with GERD as it may exacerbate symptoms. Diluting the child's formula with equal parts of water (Choice C) can lead to inadequate nutrition and is not advisable. Offering 10% dextrose in water between most feedings (Choice D) is not appropriate for managing GERD in infants and does not address the underlying issue of reflux.
5. A client on mechanical ventilation is experiencing high-pressure alarms. What action should the nurse implement first?
- A. Check the client's oxygen saturation.
- B. Assess the client's endotracheal tube for obstruction.
- C. Reposition the client to relieve pressure.
- D. Suction the client's airway.
Correct answer: B
Rationale: The correct answer is to assess the client's endotracheal tube for obstruction. When a client on mechanical ventilation experiences high-pressure alarms, the first action should be to check for any potential obstructions in the airway, which can trigger the alarms. Checking the oxygen saturation (Choice A) is important but not the priority when dealing with high-pressure alarms. Repositioning the client (Choice C) may be necessary later but should not be the initial action. Suctioning the client's airway (Choice D) should only be done after assessing for and addressing any obstructions in the endotracheal tube.