HESI RN
Maternity HESI 2023 Quizlet
1. The LPN/LVN is preparing a client with a term pregnancy who is in active labor for an amniotomy. What equipment should the nurse have available at the client's bedside? (Select all that apply.)
- A. Litmus paper.
- B. Fetal scalp electrode.
- C. A sterile glove.
- D. An amniotic hook.
Correct answer: C,D
Rationale: For performing an amniotomy, the nurse should have a sterile glove to maintain asepsis and an amniotic hook to rupture the amniotic sac. Litmus paper is not required for this procedure, and a fetal scalp electrode is used for fetal monitoring, not for an amniotomy.
2. A client with diabetes insipidus is being treated with desmopressin. The nurse should monitor for which of the following side effects?
- A. Hyponatremia
- B. Hypernatremia
- C. Hypokalemia
- D. Hypercalcemia
Correct answer: A
Rationale: The correct answer is A: Hyponatremia. Desmopressin, a medication used in diabetes insipidus, can cause water retention by increasing water reabsorption in the kidneys. This excess water retention can lead to dilutional hyponatremia, where sodium levels in the body become too low. Monitoring for hyponatremia is crucial to prevent complications such as neurological symptoms. Choices B, C, and D are incorrect because desmopressin is not known to cause hypernatremia, hypokalemia, or hypercalcemia.
3. A middle school student was recently diagnosed with attention-deficit hyperactivity disorder (ADHD) and is having trouble with his grades. He is referred to the school nurse by the teacher because he continues to have learning problems. Which action should the school nurse take?
- A. Ask the parents to have the child seen by a clinical psychologist
- B. Ask the parents to become involved in helping the child with his homework
- C. Refer the child to the school counselor for educational testing
- D. Seek the advice of the school principal regarding the child's learning needs
Correct answer: C
Rationale: Referring the child to the school counselor for educational testing is the most appropriate action in this scenario. This step can help identify the specific learning needs of the student and determine the appropriate interventions required to support his academic success. Option A is not the immediate action needed but may be considered in the future. Option B focuses on homework assistance, which may not address the underlying learning problems. Option D involves consulting the school principal, which is not the primary role in addressing the student's learning needs.
4. A community health nurse is working with a local organization to address food insecurity. Which action should the nurse prioritize?
- A. organizing a food drive to collect non-perishable items
- B. creating a community garden to grow fresh produce
- C. establishing a weekly meal program for those in need
- D. partnering with local businesses to donate food
Correct answer: C
Rationale: The correct answer is establishing a weekly meal program for those in need. This action prioritizes providing consistent and reliable access to food for individuals experiencing food insecurity. While organizing a food drive (Choice A) and partnering with local businesses to donate food (Choice D) are helpful, they may not offer a sustainable solution for ongoing food needs. Creating a community garden (Choice B) may promote self-sufficiency and access to fresh produce, but it may not address the immediate food needs of individuals who are food insecure. Therefore, establishing a weekly meal program is the most effective choice to ensure regular access to food for those in need.
5. What is the measurement of the breast areola?
- A. 3.5cm
- B. 2.5cm
- C. 4.5cm
- D. 1.5cm
Correct answer: B
Rationale: The correct answer is 2.5 cm. The average measurement of the areola is approximately 2.5 cm. Choices A, C, and D are incorrect as they do not align with the typical measurement of the breast areola.