HESI RN
HESI Quizlet Fundamentals
1. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?
- A. Leave the body as is, no preparation needed
- B. Bathe the body and place ID tags on it
- C. Remove dentures before bathing the body
- D. Position the body with its head down and arms folded on its chest
Correct answer: B
Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.
2. The nurse is monitoring a client who is receiving continuous ambulatory peritoneal dialysis. The nurse should notify the physician of which of the following findings?
- A. Clear dialysate outflow.
- B. Cloudy dialysate outflow.
- C. Decreased urine output.
- D. Increased blood pressure.
Correct answer: B
Rationale: Cloudy dialysate outflow is an indication of peritonitis, a serious complication of peritoneal dialysis that requires immediate medical attention. Clear dialysate outflow is a normal finding indicating proper dialysis function and should not raise concern. Decreased urine output may be expected in a client undergoing dialysis due to the removal of excess fluids from the body. Increased blood pressure is a common complication in clients with kidney disease but is not directly related to cloudy dialysate outflow.
3. A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with pneumonia. Which finding requires immediate intervention?
- A. Oxygen saturation of 88%
- B. Respiratory rate of 24 breaths per minute
- C. Heart rate of 90 beats per minute
- D. Productive cough with green sputum
Correct answer: D
Rationale: In a client with COPD admitted with pneumonia, a productive cough with green sputum indicates a potential bacterial infection. Green sputum is commonly associated with bacterial pneumonia, which requires immediate intervention with appropriate antibiotics. Monitoring oxygen saturation, respiratory rate, and heart rate are essential in COPD patients, but the presence of green sputum suggests an urgent need for targeted treatment to address the underlying infection. Oxygen saturation of 88% is concerning but may not directly indicate the need for immediate intervention in the absence of other critical symptoms. Respiratory rate of 24 breaths per minute and a heart rate of 90 beats per minute are within normal limits and may not be indicative of an acute issue requiring immediate intervention in this context.
4. The client has a new prescription for metoclopramide (Reglan). On review of the chart, the nurse identifies that this medication can be safely administered with which condition?
- A. Intestinal obstruction
- B. Peptic ulcer with melena
- C. Diverticulitis with perforation
- D. Vomiting following cancer chemotherapy
Correct answer: D
Rationale: Metoclopramide, also known as Reglan, is commonly used to manage vomiting following cancer chemotherapy. It acts as a gastrointestinal stimulant and antiemetic, aiding in relieving nausea and vomiting associated with chemotherapy. Metoclopramide should be avoided in conditions like intestinal obstruction, peptic ulcer with melena, and diverticulitis with perforation due to its prokinetic properties that can worsen these conditions. Therefore, the correct answer is D: Vomiting following cancer chemotherapy.
5. Which of the following actions by the healthcare provider would be considered false imprisonment?
- A. The healthcare provider tells the client they are not allowed to leave until the physician has released them.
- B. The healthcare provider asks the client why they wish to leave.
- C. The healthcare provider asks the client to explain what they understand about their medical diagnosis.
- D. The healthcare provider asks the client to sign an against medical advice discharge form.
Correct answer: A
Rationale: The correct answer is A. False imprisonment occurs when a healthcare provider restrains a client from leaving against their will, even if the provider believes it is in the client's best interest. In this scenario, telling the client they are not allowed to leave until the physician has released them constitutes false imprisonment as it restricts the client's freedom of movement. Choice B is incorrect because asking the client why they wish to leave is a form of assessment and does not involve restraining the client. Choice C is incorrect as it pertains to educating the client about their medical condition. Choice D is incorrect because asking the client to sign an against medical advice discharge form is a legal and ethical procedure to ensure the client understands the risks of leaving against medical advice.