HESI RN
HESI Quizlet Fundamentals
1. A client in the early stages of Alzheimer’s disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client’s anxiety?
- A. Remind the client that her parents have passed away
- B. Ask the client about her favorite memories with her parents
- C. Engage the client in an activity to distract her from thinking about her parents
- D. Reorient the client to the present reality and surroundings
Correct answer: C
Rationale: Engaging the client in an activity to distract her from thinking about her deceased parents is the most appropriate intervention to reduce anxiety. This approach helps shift the focus away from distressing thoughts and can provide comfort and a sense of calm to the client.
2. Which assessment data indicates the need for the nurse to include the problem 'Risk for falls' in a client’s plan of care?
- A. Recent serum hemoglobin level of 16 g/dL
- B. Opioid analgesic received one hour ago
- C. Stooped posture with an unsteady gait
- D. Expressed feelings of depression
Correct answer: B
Rationale: The correct answer is B. The administration of opioid analgesics can impair balance and increase the risk of falls, justifying the inclusion of 'Risk for falls' in the client’s care plan. Choice A, a recent serum hemoglobin level of 16 g/dL, is not directly related to the risk of falls. Choice C, stooped posture with an unsteady gait, may indicate a risk for falls, but the direct influence of opioid analgesics on balance is more immediate. Choice D, expressed feelings of depression, while important, is not a direct indicator of the immediate risk for falls associated with opioid analgesic use.
3. After ensuring correct tube placement, what action should the nurse take next when administering medications through a nasogastric tube (NGT) connected to suction?
- A. Clamp the tube for 20 minutes.
- B. Flush the tube with water.
- C. Administer the medications as prescribed.
- D. Crush the tablets and dissolve in sterile water.
Correct answer: B
Rationale: After ensuring the correct placement of the NGT, the nurse should flush the tube with water to prevent any obstructions and ensure proper medication delivery. Flushing the tube is essential before, after, and in between each medication administration. Clamping the tube for 20 minutes should be done after all medications are administered to prevent clogging. Administering medications as prescribed and preparing medications by crushing tablets and dissolving them in sterile water should only be done after the tube has been appropriately flushed to maintain its patency and effectiveness.
4. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?
- A. Confirm the finding by further assessing the client for jugular vein distention.
- B. Offer the client high-protein snacks between regularly scheduled mealtimes.
- C. Continue the planned nursing interventions to restore the client's fluid volume.
- D. Change the plan of care to include interventions for impaired skin integrity.
Correct answer: C
Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.
5. A client is admitted with a diagnosis of acute pancreatitis. Which assessment finding is most indicative of this diagnosis?
- A. Epigastric pain that radiates to the back.
- B. Abdominal pain with guarding.
- C. Nausea and vomiting.
- D. Increased bowel sounds in all quadrants.
Correct answer: A
Rationale: Epigastric pain that radiates to the back (A) is the hallmark assessment finding of acute pancreatitis. The pancreas lies retroperitoneally in the upper abdomen, so inflammation often causes severe epigastric pain that radiates through to the back. While abdominal pain with guarding (B), nausea and vomiting (C), and increased bowel sounds (D) can also be present in acute pancreatitis, they are less specific and may be seen in various other gastrointestinal conditions. Therefore, the most indicative finding for acute pancreatitis is epigastric pain that radiates to the back.
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