HESI RN
HESI Fundamentals Quizlet
1. The mental health nurse plans to discuss a client's depression with the health care provider in the emergency department. There are two clients sitting across from the emergency department desk. Which nursing action is best?
- A. Only refer to the client by gender.
- B. Identify the client only by age.
- C. Avoid using the client's name.
- D. Discuss the client another time.
Correct answer: D
Rationale: The best nursing action is to discuss the client another time. When discussing a client's confidential information, it is essential to ensure privacy and confidentiality. Given the presence of other clients in the immediate vicinity, it is inappropriate to discuss personal details about a client's condition openly. Waiting for a more private setting is crucial to uphold the client's right to privacy and confidentiality. Choices A, B, and C are not appropriate because referring to the client only by gender, age, or avoiding the client's name does not address the issue of discussing confidential information in a public setting, which compromises the client's privacy and confidentiality.
2. The nurse is preparing to administer an immunization to a 5-year-old child. The parent asks if the vaccine can be given in a different way because the child is afraid of needles. What is the nurse’s best response?
- A. We can apply a numbing cream before the injection
- B. There is no other way to administer this vaccine
- C. We can give the vaccine as a nasal spray
- D. We can skip the vaccine if the child is too afraid
Correct answer: C
Rationale: Administering the vaccine as a nasal spray provides an alternative method of delivery that avoids the use of needles, addressing the child's fear while ensuring immunization. Nasal sprays are effective for certain vaccines and can be a suitable option in this scenario. Choice A is not the best response as it only addresses pain management but does not eliminate the use of needles. Choice B is incorrect as there are alternative delivery methods like nasal sprays. Choice D is incorrect as skipping the vaccine would leave the child unprotected and is not a recommended course of action.
3. A client with cirrhosis is prescribed spironolactone to manage ascites. Which serum laboratory value is most important for the nurse to monitor?
- A. Sodium
- B. Calcium
- C. Magnesium
- D. Potassium
Correct answer: D
Rationale: The correct answer is D: Potassium. Spironolactone is a potassium-sparing diuretic, which can lead to hyperkalemia. Monitoring potassium levels is crucial to prevent complications like cardiac arrhythmias. Choices A, B, and C are incorrect because sodium, calcium, and magnesium levels are not directly affected by spironolactone use for managing ascites in cirrhosis.
4. A water molecule contains two types of atoms that are covalently bonded. Which of the following makes up a water molecule?
- A. One hydrogen atom and one oxygen atom
- B. One hydrogen atom and two oxygen atoms
- C. Two hydrogen atoms and two oxygen atoms
- D. Two hydrogen atoms and one oxygen atom
Correct answer: D
Rationale: The correct answer is D: Two hydrogen atoms and one oxygen atom. A water molecule consists of two hydrogen atoms covalently bonded to one oxygen atom. This forms a stable structure known as H2O. Choice A is incorrect as water molecule contains two hydrogen atoms. Choices B and C are incorrect as they do not reflect the correct composition of a water molecule.
5. The client with chronic renal failure is receiving peritoneal dialysis. Which of the following is the most important action for the nurse to take?
- A. Administer the prescribed antibiotics.
- B. Monitor for signs of infection.
- C. Encourage the client to increase fluid intake.
- D. Monitor the client's weight daily.
Correct answer: B
Rationale: Monitoring for signs of infection is crucial in clients undergoing peritoneal dialysis. Peritonitis is a severe complication associated with peritoneal dialysis, making it essential to promptly identify any signs of infection, such as abdominal pain, cloudy dialysate, fever, and an elevated white blood cell count. Administering antibiotics without proper assessment can lead to antibiotic resistance and should not be the initial action. Encouraging increased fluid intake may not be appropriate without assessing the client's fluid status. Monitoring weight alone does not address the immediate risk of peritonitis in a client undergoing peritoneal dialysis.