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. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?
- A. Check the bath water temperature.
- B. Shut the bathroom door.
- C. Ensure that the client has voided.
- D. Provide extra towels.
Correct answer: A
Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.
3. While observing an unlicensed assistive personnel (UAP) providing a total bed bath for a confused and lethargic client, the nurse notes the UAP soaking the client’s foot in a basin of warm water placed on the bed. What action should the nurse take?
- A. Remove the basin of water from the client’s bed immediately
- B. Remind the UAP to dry between the client’s toes completely
- C. Advise the UAP that this procedure may lead to skin damage
- D. Add skin cream to the basin of water while the foot is soaking
Correct answer: B
Rationale: The correct action for the nurse to take in this situation is to remind the unlicensed assistive personnel (UAP) to dry between the client’s toes completely. Failing to dry between the toes can lead to skin breakdown due to excessive moisture accumulation. Proper drying is essential to maintain skin integrity and prevent complications in the client's care. Removing the basin of water immediately may disrupt the care process and not address the root cause of the issue. Advising about potential skin damage is not as direct and actionable as reminding to dry between the toes. Adding skin cream to the water may not be appropriate without specific orders and can potentially worsen the situation by increasing moisture.
4. A female UAP is assigned to take the vital signs of a client with pertussis for whom droplet precautions have been implemented. The UAP requests a change in assignment because she has not yet been fitted for a particulate filter mask. Which action should the nurse take?
- A. Advise the UAP to wear a standard face mask to take vital signs and then get fitted for a filter mask before providing personal care.
- B. Send the UAP to be fitted for a particulate filter mask immediately so she can provide care to this client.
- C. Instruct the UAP that a standard mask is sufficient for the provision of care for the assigned client.
- D. Before changing assignments, determine which staff members have fitted particulate filter masks.
Correct answer: C
Rationale: The correct answer is C. For droplet precautions, such as in the case of pertussis, a standard face mask is sufficient for protection. Particulate filter masks are required for airborne precautions, not for droplet precautions. Therefore, the UAP can proceed with taking the vital signs using a standard mask without the need for a particulate filter mask. Choice A is incorrect because the UAP does not need to get fitted for a particulate filter mask before providing care in this situation. Choice B is incorrect as fitting for a particulate filter mask is not necessary for droplet precautions. Choice D is also incorrect because determining which staff members have fitted particulate filter masks is not relevant to the UAP's situation with the client on droplet precautions. It is important for healthcare workers to understand the appropriate use of personal protective equipment based on the type of precautions in place to provide safe and effective care to clients.
5. A healthcare professional stops at a motor vehicle collision site to render aid until the emergency personnel arrive and applies pressure to a groin wound that is bleeding profusely. Later, the client has to have the leg amputated and sues the healthcare professional for malpractice. What is the most likely outcome of this lawsuit?
- A. The Patient's Bill of Rights protects clients from malicious intents, so the healthcare professional could lose the case.
- B. The lawsuit may be settled out of court, but the healthcare professional's license is likely to be revoked.
- C. There will be no judgment against the healthcare professional, whose actions were protected under the Good Samaritan Act.
- D. The client will win because the four elements of negligence (duty, breach, causation, and damages) can be proved.
Correct answer: C
Rationale: The Good Samaritan Act protects healthcare professionals who provide care in good faith and offer reasonable assistance in emergencies. This law shields them from malpractice claims, even if the outcome for the client is unfavorable. In this scenario, the healthcare professional is likely to be protected from judgment under the Good Samaritan Act. Choice A is incorrect because the situation does not involve the Patient's Bill of Rights, but rather the Good Samaritan Act. Choice B is incorrect as the license revocation is not a typical outcome in Good Samaritan cases. Choice D is incorrect as the Good Samaritan Act provides immunity from liability in such emergency situations.
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