HESI RN
HESI Quizlet Fundamentals
1. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?
- A. Reassure the client that many obese individuals have concerns about sex.
- B. Remind the client that sexual relationships can be maintained regardless of weight.
- C. Determine the frequency of sexual intercourse.
- D. Ask the client to talk about specific concerns.
Correct answer: D
Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.
2. Lactational Amenorrhoea Method (LAM) is best for:
- A. Clients who do not wish to have any more children
- B. Clients with a baby less than 6 months postpartum
- C. Clients who want to wait before having a first or another child
- D. Clients with several sexual partners
Correct answer: B
Rationale: The correct answer is B: Clients with a baby less than 6 months postpartum. Lactational Amenorrhoea Method (LAM) is a highly effective temporary family planning method that is recommended for women who have recently given birth and are breastfeeding. LAM works best when the baby is less than 6 months old, the mother is exclusively breastfeeding, and her menstrual periods have not resumed. Choices A, C, and D are incorrect because LAM is specifically designed for postpartum women with infants less than 6 months old, focusing on the lactational infertility that occurs during exclusive breastfeeding.
3. A client is being taught about the use of enoxaparin (Lovenox) for the prevention of deep vein thrombosis. Which instruction should the nurse include in the teaching plan?
- A. Inject the medication subcutaneously.
- B. Avoid massaging the injection site after administration.
- C. Administer the medication at the same time each day.
- D. Do not expel the air bubble from the syringe before injection.
Correct answer: C
Rationale: Enoxaparin (Lovenox) is administered subcutaneously at the same time each day to maintain consistent blood levels. Injecting the medication into the muscle is incorrect, as it should be given subcutaneously. Massaging the injection site should be avoided to prevent bruising. The air bubble in the prefilled syringe should not be expelled, as it ensures the full dose is administered.
4. A client is receiving total parenteral nutrition (TPN). Which of these interventions should the nurse perform to reduce the risk of infection?
- A. Changing the TPN tubing and solution every 24 hours
- B. Monitoring the TPN infusion rate closely
- C. Keeping the head of the bed elevated
- D. Ensuring the solution is at room temperature before infusing
Correct answer: A
Rationale: The correct answer is to change the TPN tubing and solution every 24 hours to reduce the risk of infection. This practice helps prevent microbial growth and contamination in the TPN solution. Monitoring the infusion rate closely (choice B) is important for preventing metabolic complications but does not directly reduce the risk of infection. Keeping the head of the bed elevated (choice C) is beneficial for preventing aspiration in feeding tube placement but is unrelated to reducing infection risk in TPN. Ensuring the solution is at room temperature before infusing (choice D) is essential for patient comfort and preventing metabolic complications but does not specifically address infection risk reduction.
5. The nurse provides feeding tube instructions to the wife of a client with end-stage cancer. The client's wife performs a return demonstration correctly but begins crying and tells the nurse, 'I just don't think I can do this every day.' The nurse should direct further teaching strategies toward which learning domain?
- A. Cognitive.
- B. Affective.
- C. Comprehension.
- D. Psychomotor.
Correct answer: B
Rationale: The correct answer is B: Affective. The affective domain involves feelings and emotions, which are significant factors in the wife’s ability to cope and perform the required care. In this scenario, the wife's emotional response indicates a need for further support and teaching strategies to address her emotional concerns and build her confidence. Choices A, C, and D are incorrect because the issue at hand is not purely cognitive (knowledge), comprehension (understanding), or psychomotor (physical skills), but rather an emotional response that falls under the affective domain.