HESI RN
HESI Fundamentals Practice Test
1. After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?
- A. Complete an incident report.
- B. Select another sterile needle.
- C. Disinfect the needle with an alcohol swab.
- D. Notify the supervisor immediately.
Correct answer: B
Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.
2. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
- A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
- B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
- C. Assist the client to a standing position by gently lifting upward underneath the axillae.
- D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Correct answer: B
Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.
3. A client with frequent urinary tract infections (UTIs) asks the nurse about drinking juice daily to prevent future UTIs. Which response is best for the nurse to provide?
- A. Orange juice has vitamin C, which deters bacterial growth.
- B. Apple juice is the most useful in acidifying the urine.
- C. Cranberry juice stops pathogens' adherence to the bladder.
- D. Grapefruit juice increases the absorption of most antibiotics.
Correct answer: C
Rationale: Cranberry juice is known for its ability to prevent urinary tract infections by reducing the adherence of Escherichia coli bacteria to the cells within the bladder. This property helps in maintaining urinary tract health and preventing recurrent UTIs. Choices A, B, and D are incorrect because while vitamin C in orange juice may have some benefits, it is not specifically known for deterring bacterial growth in the urinary tract. Apple juice does not significantly impact urine acidity, and grapefruit juice does not enhance antibiotic absorption, making them less effective choices for preventing UTIs compared to cranberry juice.
4. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
- A. Increase fluid intake to 3 liters per day.
- B. Limit sodium intake to 2 grams per day.
- C. Avoid foods high in potassium.
- D. Increase protein intake to promote healing.
Correct answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.
5. A client is admitted with a stage four pressure ulcer that has a black, hardened surface and a light-pink wound bed with malodorous green drainage. Which dressing is best for the nurse to use first?
- A. Hydrogel dressing.
- B. Exudate absorber.
- C. Wet-to-moist dressing.
- D. Transparent adhesive film.
Correct answer: C
Rationale: The best initial dressing for a stage four pressure ulcer with necrotic tissue is a wet-to-moist dressing. This dressing helps to provide moisture, soften necrotic tissue, and prepare the wound bed for healing. It promotes autolytic debridement and can help manage malodorous drainage. Once the necrotic tissue is loosened, other advanced dressings like hydrogel or alginate may be used in the wound bed to facilitate healing.
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