a nurse observes a student nurse taking a copy of a clients medication administration record when questioned the student states another student is sch
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

2. What instruction should be provided for a UAP caring for a client with MRSA who has an order for contact precautions?

Correct answer: D

Rationale: The correct instruction for a UAP caring for a client with MRSA under contact precautions is to don a gown and gloves when entering the client's room. This precaution is essential to prevent the spread of MRSA and protect both the client and the healthcare worker from potential infection. Choice A is incorrect because visitors should not be restricted solely based on contact precautions. Choice B is incorrect as wearing sterile gloves is not necessary, standard precautions with regular gloves are sufficient. Choice C is incorrect because the client wearing a mask is not a standard practice for contact precautions; it is the healthcare worker who should take preventive measures.

3. The healthcare provider receives a report that a client with an indwelling urinary catheter has an output of 150 mL for the previous 6-hour shift. Which intervention should the healthcare provider implement first?

Correct answer: A

Rationale: The first intervention should be to check the drainage tubing for a kink. This step is crucial as any kinks in the tubing could obstruct urine flow, leading to a decreased output. By ensuring the tubing is free from any obstructions, the healthcare provider can address a potential mechanical issue causing the low output before considering other interventions. Reviewing the intake and output record may provide valuable information but should come after ensuring the tubing is clear. Notifying the healthcare provider can be done later if needed, but the immediate concern is to check for any obstructions. Giving the client water to drink may be necessary depending on the assessment findings, but addressing a possible kink in the tubing takes precedence.

4. A client is admitted with a diagnosis of diabetic ketoacidosis (DKA). Which assessment finding should the nurse anticipate?

Correct answer: B

Rationale: Kussmaul respirations (B) are a deep and labored breathing pattern associated with diabetic ketoacidosis (DKA) and are expected in this condition. While oliguria (A), fruity odor on the breath (C), and elevated blood glucose level (D) are also signs of DKA, Kussmaul respirations are more specific and critical to the condition, indicating severe metabolic acidosis.

5. The healthcare provider is preparing an older client for discharge. Which method is best for the provider to use when evaluating the client's ability to perform a dressing change at home?

Correct answer: D

Rationale: Direct observation of the client performing the skill is the most effective method to assess the client's ability to independently change the dressing. This allows the healthcare provider to evaluate the client's technique, understanding, and readiness to perform the task at home. Choices A, B, and C are not as reliable as directly observing the client performing the dressing change. Determining the client's feelings may not accurately reflect their ability, asking the client to write about the procedure may not demonstrate their practical skills, and having a family member evaluate might not provide an accurate assessment of the client's ability.

Similar Questions

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