HESI RN
Community Health HESI Quizlet
1. The client is unable to void, and the plan of care sets an objective for the client to ingest at least 1000 mL of fluid between 7:00 am and 3:30 pm. Which client response should the nurse document to indicate a successful outcome?
- A. Drinks adequate fluids.
- B. Void without difficulty.
- C. Feels less thirsty.
- D. Drinks 240 mL of fluid five times during the shift.
Correct answer: D
Rationale: The correct answer is D. Drinking 240 mL of fluid five times during the shift indicates a fluid intake of 1200 mL, which exceeds the minimum objective of at least 1000 mL. The client meeting or exceeding the fluid intake goal is a clear indicator of a successful outcome. Choices A, B, and C are incorrect because simply drinking adequate fluids, voiding without difficulty, or feeling less thirsty do not directly demonstrate meeting the specific objective of fluid intake set in the care plan.
2. The nurse explains to an older adult male the procedure for collecting a 24-hour urine specimen for creatinine clearance. Which action is most important for the nurse to include in their care plan for the shift?
- A. Assess the client for confusion and reteach the procedure
- B. Check the urine for color and texture
- C. Empty the urinal contents into the 24-hour collection container
- D. Discard the contents of the urinal
Correct answer: C
Rationale: To ensure accurate creatinine clearance results, it is crucial to collect all urine within the 24-hour period. The process should begin with discarding the first specimen and then collecting all subsequent urine in the designated 24-hour collection container. This ensures that the sample is complete and accurate for the creatinine clearance calculation.
3. What is the triangular space lying between the vaginal and rectal canals?
- A. Pelvic floor
- B. Perineum
- C. Vestibule
- D. Perineal body
Correct answer: B
Rationale: The correct answer is B: Perineum. The perineum is the triangular space located between the vaginal and rectal canals. It is a region containing various muscles, nerves, and blood vessels that support the pelvic floor. Choice A, Pelvic floor, refers to the structure supporting the organs in the pelvic cavity, not the space between the vaginal and rectal canals. Choice C, Vestibule, is the space within the labia minora containing the openings of the urethra and vagina, not the area between the vaginal and rectal canals. Choice D, Perineal body, is a fibromuscular mass in the perineum area but not the space between the vaginal and rectal canals.
4. A client is receiving morphine for postoperative pain. What is the nurse's priority assessment?
- A. Monitor the client's respiratory rate.
- B. Monitor the client's level of consciousness.
- C. Assess the client's level of pain.
- D. Monitor the client's blood pressure.
Correct answer: A
Rationale: The correct answer is to monitor the client's respiratory rate. Morphine can cause respiratory depression, so assessing the respiratory rate is crucial to detect this potential side effect early. Monitoring the client's level of consciousness (Choice B) is important but comes after ensuring adequate breathing. Assessing the client's pain level (Choice C) is essential but not the priority when dealing with the side effects of morphine. Monitoring the client's blood pressure (Choice D) is also important but not the priority assessment when the focus is on respiratory depression.
5. What is Dinoprostone commonly used for?
- A. Cervical priming.
- B. Pain management during labor.
- C. Management of pre-term labor.
- D. Management of post-partum hemorrhage.
Correct answer: C
Rationale: Dinoprostone is commonly used for the management of pre-term labor. While it can be used for cervical priming, its primary indication is for pre-term labor. Choice A is partially correct but not the most common use of Dinoprostone. Choices B and D are incorrect as Dinoprostone is not primarily used for pain management during labor or for the management of post-partum hemorrhage.