HESI RN
HESI Quizlet Fundamentals
1. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?
- A. Release the suction by opening the vent.
- B. Continue suctioning to remove obstruction.
- C. Increase the pressure.
- D. Suction deeper.
Correct answer: A
Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.
2. A male client with chronic kidney disease (CKD) is refusing to take his medication and has missed two hemodialysis appointments. What is the best initial action for the nurse?
- A. Discuss what the treatment regimen means to him.
- B. Refer the client to a mental health nurse practitioner.
- C. Reschedule the appointments to another date and time.
- D. Discuss the option of peritoneal dialysis.
Correct answer: A
Rationale: The best initial action for the nurse in this scenario is to have a discussion with the client about what the treatment regimen means to him. It is important to assess the client's anxiety, coping styles, and acceptance of the required treatment for CKD. The client may be in denial of the diagnosis or may have concerns that need to be addressed. While rescheduling hemodialysis appointments could be helpful, referring the client to a mental health nurse practitioner or discussing peritoneal dialysis are not the most appropriate first steps. Understanding the client's perspective and concerns is crucial before exploring other interventions.
3. A client with diabetes is being educated about the dietary source that should provide the greatest percentage of their calories. Which of the following statements by the client indicates an understanding of the teaching?
- A. Most of my calories each day should be from fats.
- B. I should eat more calories from complex carbohydrates than anything else.
- C. Simple sugars are needed more than other calorie sources.
- D. Protein should be my main source of calories.
Correct answer: B
Rationale: The correct answer is B. In diabetes management, complex carbohydrates should constitute the largest portion of the diet as they help in maintaining steady energy levels and managing blood sugar. Choice A is incorrect because a high-fat diet can lead to complications in diabetes. Choice C is incorrect as simple sugars can cause rapid spikes in blood sugar levels. Choice D is incorrect as protein, while important, should not be the main source of calories for a diabetic individual.
4. The healthcare provider is caring for a client with hyperparathyroidism. Which laboratory result requires immediate intervention?
- A. Serum calcium of 11 mg/dL.
- B. Serum phosphorus of 3 mg/dL.
- C. Serum magnesium of 1.8 mg/dL.
- D. Serum albumin of 4 g/dL.
Correct answer: A
Rationale: A serum calcium level of 11 mg/dL indicates hypercalcemia, which can be a complication of hyperparathyroidism and requires immediate intervention. Hypercalcemia can lead to serious complications such as cardiac dysrhythmias, renal failure, and neurologic symptoms. Monitoring and managing serum calcium levels are crucial in clients with hyperparathyroidism. Serum phosphorus, magnesium, and albumin levels are important to assess in clients with hyperparathyroidism, but they do not require immediate intervention as hypercalcemia poses a more urgent risk.
5. What is the most common side effect of diuretics such as furosemide (Lasix)?
- A. Hypokalemia.
- B. Hyperkalemia.
- C. Hypernatremia.
- D. Hyponatremia.
Correct answer: A
Rationale: The correct answer is 'Hypokalemia.' Diuretics like furosemide increase the excretion of potassium, leading to hypokalemia as a common side effect. Hyperkalemia (choice B) is the opposite condition characterized by high potassium levels, which is not typically associated with furosemide use. Hypernatremia (choice C) is increased sodium levels, while hyponatremia (choice D) is decreased sodium levels, neither of which are the most common side effects of furosemide. Therefore, choice A is the best answer.