HESI RN
Adult Health 2 HESI Quizlet
1. Before leaving the room of a confused client, the nurse notes that a half bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?
- A. Tie the knot with a double turn or square knot
- B. Ensure that the restraints are snug against the client's wrists
- C. Ensure that the knot can be quickly released
- D. Move the ties so the restraints are secured to the side rails
Correct answer: C
Rationale: The priority is to ensure that the knot can be quickly released to allow for quick intervention if necessary. Tying the knot with a double turn or square knot (Choice A) may make it more difficult to release quickly in an emergency. Ensuring that the restraints are snug against the client's wrists (Choice B) may compromise circulation and cause discomfort. Moving the ties to secure the restraints to the side rails (Choice D) is not the appropriate action as it can limit the client's movement and access to care.
2. The client is being taught about the best time to plan sexual intercourse in order to conceive. Which information should be provided?
- A. Two weeks before menstruation.
- B. Vaginal mucous discharge is thick.
- C. Low basal temperature.
- D. First thing in the morning.
Correct answer: A
Rationale: The correct answer is A: 'Two weeks before menstruation.' Ovulation typically occurs 14 days before menstruation begins during a typical 28-day cycle. To increase the chances of conception, sexual intercourse should occur within 24 hours of ovulation. High estrogen levels during ovulation lead to changes in vaginal mucous discharge, making it more 'slippery' and stretchy. Basal temperature rises during ovulation. The timing of intercourse during the day is less significant than ensuring it happens around ovulation. The other options are incorrect because planning intercourse two weeks before menstruation is likely to miss the fertile window, thick vaginal mucous discharge indicates ovulation is approaching, and low basal temperature is not indicative of the fertile period.
3. The healthcare provider is assessing a client with hypothyroidism. Which of the following clinical findings would the healthcare provider expect?
- A. Tachycardia
- B. Weight loss
- C. Cold intolerance
- D. Diaphoresis
Correct answer: C
Rationale: Cold intolerance is a classic symptom of hypothyroidism. In hypothyroidism, the body's metabolic rate is decreased, leading to a reduced ability to regulate body temperature. As a result, individuals with hypothyroidism often feel cold, especially in their extremities. Tachycardia (A) is more commonly associated with hyperthyroidism due to the increased metabolic rate. Weight loss (B) is also a typical finding in hyperthyroidism, as the body burns calories at a faster rate. Diaphoresis (D), excessive sweating, is not a typical symptom of hypothyroidism.
4. A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?
- A. Administer a diuretic as prescribed
- B. Restrict the child’s fluid intake
- C. Notify the healthcare provider
- D. Measure the child’s abdominal girth
Correct answer: C
Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.
5. A nurse manager is reviewing the nurse’s documentation on the unit. Which of the following best describes the importance of this review?
- A. The nurse manager’s review of documentation is crucial to ensure that it meets legal and ethical standards and accurately reflects the care provided to patients.
- B. The nurse manager’s review of documentation is important to ensure that it is thorough, accurate, and reflects the nurse’s accountability for patient care.
- C. The nurse manager’s review of documentation is necessary to ensure that it is consistent with the unit’s policies and procedures and that it accurately reflects the care provided.
- D. The nurse manager’s review of documentation is essential to ensure that it meets regulatory requirements and that it supports the delivery of safe and effective patient care.
Correct answer: D
Rationale: The nurse manager's review of documentation is a critical aspect of maintaining quality patient care. Choice D is the correct answer as it highlights the importance of ensuring that documentation meets regulatory requirements, supporting the delivery of safe and effective patient care. Regulatory requirements are established to ensure that healthcare facilities function within established guidelines and standards, promoting patient safety and quality of care. Choices A, B, and C, although important aspects of documentation review, do not fully encapsulate the significant role of regulatory compliance in ensuring the overall quality and safety of patient care.