HESI RN
HESI Maternity Test Bank
1. An infant delivered vaginally by an HIV-positive mother is admitted to the newborn nursery. What intervention should the healthcare provider perform first?
- A. Bathe the infant with an antimicrobial soap.
- B. Measure the head and chest circumference.
- C. Obtain the infant's footprints.
- D. Administer vitamin K (AquaMEPHYTON).
Correct answer: A
Rationale: The initial intervention should be to bathe the infant with an antimicrobial soap to reduce the risk of HIV transmission from maternal fluids. This immediate action helps minimize potential exposure to the virus and promotes infection control practices in the care of infants born to HIV-positive mothers. Choice B, measuring head and chest circumference, is important for assessing growth and development but not the priority in this scenario. Choice C, obtaining footprints, is a routine procedure but not a priority over infection control measures. Choice D, administering vitamin K, is important for clotting factors but does not address the immediate risk of HIV transmission.
2. A client with a history of coronary artery disease (CAD) is admitted with chest pain. Which diagnostic test should the nurse anticipate preparing the client for first?
- A. Electrocardiogram (ECG)
- B. Chest X-ray
- C. Arterial blood gases (ABGs)
- D. Echocardiogram
Correct answer: A
Rationale: The correct answer is A: Electrocardiogram (ECG). An electrocardiogram should be performed first to assess for cardiac ischemia in a client with a history of CAD and chest pain. An ECG provides immediate information about the heart's electrical activity, helping to identify signs of ischemia or a heart attack. While other diagnostic tests like chest X-ray, arterial blood gases, and echocardiogram may also be necessary in the evaluation of chest pain, they do not provide the initial direct assessment of cardiac ischemia that an ECG does.
3. 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.
4. The nurse is preparing to administer an IM dose of vitamin B1 (Thiamine) to a male client experiencing acute alcohol withdrawal and peripheral neuritis. The client belligerently states, 'What do you think you're doing?' How should the nurse respond?
- A. I cannot give you this medication until you calm down.
- B. This shot will help relieve the pain in your feet.
- C. Would you prefer to learn to administer your own shot?
- D. You will feel calmer and less jittery after this shot.
Correct answer: B
Rationale: Choice B is the correct answer because it addresses the client's concern by explaining that the shot will help relieve the pain in his feet, which is a symptom of peripheral neuritis. This response shows empathy and provides the client with a clear benefit of receiving the medication. Choices A, C, and D do not directly address the client's immediate concern about the injection and its purpose, making them less suitable responses. Choice A focuses on the client's behavior rather than the therapeutic effect of the injection. Choice C shifts the responsibility to the client to administer the shot, which may not be appropriate in this situation. Choice D mentions feeling calmer and less jittery, which is not directly related to the client's current complaint of pain in the feet.
5. A client is receiving intravenous (IV) fluids postoperatively. Which assessment finding should prompt the nurse to stop the infusion and notify the healthcare provider?
- A. The client reports pain at the IV site
- B. The client’s blood pressure is elevated
- C. The client has swelling at the IV site
- D. The client’s heart rate is irregular
Correct answer: C
Rationale: Swelling at the IV site may indicate infiltration or phlebitis, which requires stopping the IV infusion and notifying the healthcare provider. Infiltration occurs when the IV fluid leaks into the surrounding tissue, causing swelling and potential damage. It is crucial to act promptly to prevent further complications and ensure the client's safety.