HESI RN
HESI Quizlet Fundamentals
1. The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?
- A. Remove the catheter and reinsert it with the client positioned differently.
- B. Try a straight catheter instead.
- C. Try a smaller catheter.
- D. Discontinue the procedure and notify the physician.
Correct answer: D
Rationale: If resistance is encountered, the nurse should discontinue the procedure and notify the physician, as this may indicate an obstruction.
2. The healthcare provider is caring for a client with a chest tube. Which observation indicates that the chest tube is functioning effectively?
- A. Continuous bubbling in the water-seal chamber.
- B. Intermittent bubbling in the suction control chamber.
- C. No fluctuation (tidaling) in the water-seal chamber.
- D. Drainage of clear, pale yellow fluid from the chest tube.
Correct answer: B
Rationale: Intermittent bubbling in the suction control chamber is the correct observation indicating effective functioning of the chest tube. This bubbling signifies that the suction system is working correctly and maintaining the desired negative pressure in the pleural space. Continuous bubbling in the water-seal chamber suggests an air leak, which is not a normal finding. No fluctuation (tidaling) in the water-seal chamber may indicate a blockage or lack of communication between the pleural space and the water-seal, which is not ideal. Drainage of clear, pale yellow fluid from the chest tube is a normal finding, but it does not specifically indicate the effectiveness of the chest tube function.
3. A client with type 2 diabetes is admitted with hyperglycemic hyperosmolar syndrome (HHS). Which clinical finding is most concerning to the nurse?
- A. Serum glucose of 500 mg/dL
- B. Blood pressure of 140/90 mmHg
- C. Serum osmolarity of 320 mOsm/kg
- D. Serum pH of 7.30
Correct answer: C
Rationale: A serum osmolarity of 320 mOsm/kg is the most concerning finding in a client with hyperglycemic hyperosmolar syndrome (HHS) as it indicates severe dehydration and hypertonicity. This high serum osmolarity level can lead to neurological complications and requires immediate intervention to prevent further deterioration. Serum glucose levels, blood pressure, and serum pH are important parameters to monitor in HHS, but a significantly elevated serum osmolarity poses a higher risk of complications and warrants urgent attention. High serum glucose levels, like 500 mg/dL, are expected in HHS but do not directly indicate the severity of dehydration. Blood pressure of 140/90 mmHg is within normal limits and may not be directly related to the acute complications of HHS. A serum pH of 7.30 suggests acidosis, which is important to address but may not be as immediately concerning as severe dehydration indicated by high serum osmolarity.
4. A client with chronic renal failure is being discharged with a prescription for erythropoietin (Epogen). Which statement indicates that the client understands the action of this medication?
- A. It helps my body make red blood cells
- B. It helps prevent infections
- C. It helps my kidneys excrete excess fluid
- D. It helps me breathe easier
Correct answer: A
Rationale: The correct answer is A: 'It helps my body make red blood cells.' Erythropoietin is a medication that stimulates the production of red blood cells in the body. Clients with chronic renal failure often develop anemia due to decreased erythropoietin production by the kidneys. This medication helps address that issue by increasing red blood cell production. Choices B, C, and D are incorrect because erythropoietin does not prevent infections, help kidneys excrete excess fluid, or assist with breathing; its primary action is to boost red blood cell production.
5. Discuss the anatomical/physiological changes in pregnancy related to the breasts.
- A. Breast tenderness increases, circulatory supply to the breasts increases, leading to breast enlargement, and colostrum secretion occurs.
- B. Breast tenderness decreases, and there is no significant change in breast size.
- C. Breast changes include decreased tenderness and reduced circulatory supply.
- D. Breasts do not undergo significant changes during pregnancy.
Correct answer: A
Rationale: During pregnancy, the breasts undergo significant anatomical and physiological changes. These changes include increased breast tenderness, an increase in circulatory supply to the breasts, resulting in breast enlargement, and the secretion of colostrum. Choice B is incorrect as breast tenderness actually increases during pregnancy. Choice C is incorrect as the circulatory supply to the breasts increases rather than reduces. Choice D is incorrect as breasts do undergo notable changes during pregnancy.