HESI RN
HESI Fundamentals Quizlet
1. The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?
- A. Monitor daily weights
- B. Assess skin turgor
- C. Evaluate blood pressure trends
- D. Check urine specific gravity
Correct answer: A
Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time. Assessing skin turgor (choice B) is subjective and may not provide as accurate or measurable data as monitoring daily weights. Evaluating blood pressure trends (choice C) can give information about circulatory status but may not directly reflect fluid volume status. Checking urine specific gravity (choice D) can indicate the concentration of urine but does not provide a comprehensive assessment of overall fluid balance like monitoring daily weights does.
2. A client has just returned to the nursing unit after computerized tomography (CT) with contrast medium. Which of the following actions should the nurse plan to take as part of routine after-care for this client?
- A. Administering a laxative
- B. Encouraging fluid intake
- C. Maintaining the client on strict bed rest
- D. Holding all medications for at least 2 hours
Correct answer: B
Rationale: After CT scanning with contrast medium, the client does not require special restrictions or interventions. Encouraging fluid intake is important to help flush out the contrast dye and prevent dehydration. Administering a laxative (Choice A) is unnecessary and not indicated after CT with contrast. Maintaining the client on strict bed rest (Choice C) is not necessary unless specified by the healthcare provider. Holding all medications for at least 2 hours (Choice D) is not a standard practice after CT with contrast.
3. A CVA (stroke) patient goes into respiratory distress and is placed on a ventilator. The client’s daughter arrives with a durable power of attorney and a living will that indicates there should be no extraordinary life-saving measures. What action should the nurse take?
- A. Refer to the risk manager
- B. Notify the healthcare provider
- C. Discontinue the ventilator
- D. Review the medical record
Correct answer: B
Rationale: In this situation, the nurse should notify the healthcare provider. The healthcare provider needs to be informed to review the legal documents provided by the patient's daughter, such as the durable power of attorney and living will, which specify the patient's wishes regarding life-saving measures. The healthcare provider will be responsible for making the appropriate decision based on the legal documents and the patient's current condition. Referring to the risk manager (choice A) is not necessary as the issue at hand pertains to the patient's medical care. Discontinuing the ventilator (choice C) without healthcare provider input could go against the patient's wishes and legal documents. Reviewing the medical record (choice D) may not provide immediate guidance on the current situation and the patient's preferences regarding life-saving measures.
4. An adolescent client is admitted to the psychiatric unit for self-harming behaviors. Which of the following is a priority nursing intervention?
- A. Assess the client’s suicidal ideation.
- B. Educate the client about healthy coping mechanisms.
- C. Encourage family therapy sessions.
- D. Provide a safe environment free of potential self-harm tools.
Correct answer: D
Rationale: The priority nursing intervention for an adolescent admitted for self-harming behaviors is to provide a safe environment free of potential self-harm tools. This intervention aims to prevent immediate harm to the client. Assessing suicidal ideation is important but ensuring physical safety takes precedence. While educating about healthy coping mechanisms is crucial for long-term management, immediate safety is the priority. Family therapy sessions are beneficial for holistic care but are not the immediate priority when the client's safety is at risk.
5. Laparoscopy uses a small instrument known as a laparoscope to:
- A. Take very detailed photographs
- B. Insert a hysteroscope for D&C
- C. Perform an abortion procedure
- D. Perform a hysterectomy
Correct answer: A
Rationale: Laparoscopy uses a small instrument known as a laparoscope to take very detailed photographs of the pelvic organs. This procedure is commonly used for diagnostic purposes, to visualize internal organs, and to perform minimally invasive surgeries. Choice B, inserting a hysteroscope for D&C, is incorrect as hysteroscopy is a different procedure used to examine the inside of the uterus, not the pelvic organs. Choice C, performing an abortion procedure, is incorrect as laparoscopy is not used for abortion. Choice D, performing a hysterectomy, is incorrect as although laparoscopy can be used in some cases for hysterectomy, its primary purpose is not for this procedure.