HESI RN
HESI Fundamentals Quizlet
1. The client was placed in restraints due to confusion while hospitalized. The family removes the restraints in the client's presence. After the family leaves, what should the nurse do first?
- A. Apply the restraints to ensure the client's safety.
- B. Reassess the client to determine if restraints are still necessary.
- C. Document the time the family departed and continue monitoring the client.
- D. Contact the healthcare provider for a new order.
Correct answer: B
Rationale: In this scenario, the nurse's initial action should be to reassess the client to determine if restraints are still necessary following their removal by the family. This reassessment is crucial to evaluate the client's current condition and the need for restraints before considering reapplication. By reassessing first, the nurse ensures that the client's safety is maintained while respecting their autonomy. While documentation and monitoring are important, reassessment takes priority to provide individualized and appropriate care to the client. Contacting the healthcare provider for a new order should occur after reassessment if restraints are deemed necessary.
2. When does missed abortion occur?
- A. The fetus dies and is retained in utero with the placenta and membranes.
- B. All products of conception are expelled with minimal bleeding.
- C. The cervix remains closed, and the products of conception remain in the uterus.
- D. The cervix remains closed, but there is heavy bleeding.
Correct answer: C
Rationale: Missed abortion occurs when the cervix is closed, and the products of conception remain in the uterus. Choice A describes a missed abortion, not choice C. Choice B describes a complete abortion. Choice D describes a threatened abortion, where the cervix remains closed but there is heavy bleeding.
3. The nurse is providing discharge teaching to a client with a new diagnosis of osteoporosis. Which instruction should the nurse include?
- A. Increase dietary intake of calcium-rich foods.
- B. Avoid activities that increase the risk of falls.
- C. Avoid prolonged exposure to sunlight.
- D. Increase intake of vitamin D supplements.
Correct answer: B
Rationale: Avoiding activities that increase the risk of falls (B) is the most crucial instruction for a client with osteoporosis to prevent fractures. Osteoporosis weakens bones, making them more susceptible to fractures from falls. While increasing calcium intake (A) is important for bone health, avoiding falls takes precedence to prevent immediate harm. Avoiding prolonged exposure to sunlight (C) is not directly related to osteoporosis management. Increasing vitamin D supplements (D) is beneficial for bone health, but fall prevention is more critical in this scenario.
4. The nurse is measuring the frontal occipital circumference (FOC) of a 3-month-old infant and notes that the FOC has increased by 5 inches since birth, and the child's head appears large in relation to body size. Which action is most important for the nurse to take next?
- A. Measure the infant's head-to-toe length.
- B. Palpate the anterior fontanel for tension and bulging.
- C. Observe the infant for sunken eyes.
- D. Plot the measurement on the infant's growth chart.
Correct answer: B
Rationale: Palpating the anterior fontanel for tension and bulging is crucial in assessing for increased intracranial pressure. In this scenario, the infant's large head size and rapid increase in the frontal occipital circumference raise concerns for potential issues such as hydrocephalus. Measuring the head-to-toe length (Choice A) is not the priority when assessing for increased intracranial pressure. Observing for sunken eyes (Choice C) is more indicative of dehydration rather than increased intracranial pressure. While plotting the measurement on the infant's growth chart (Choice D) is important for tracking growth, it does not address the immediate concern of assessing for increased intracranial pressure.
5. After an adult had an indwelling catheter removed, the nurse catheterizes them as ordered and obtains 200 cc of urine. What is the best interpretation of this finding?
- A. Is voiding normally.
- B. Has urinary retention.
- C. Has developed renal failure.
- D. Needs an indwelling catheter.
Correct answer: B
Rationale: The finding of obtaining 200 cc of urine after catheterization indicates urinary retention, as the bladder did not empty completely after the first void. This situation may require further assessment and intervention to address the issue of incomplete bladder emptying. Choice A is incorrect because voiding normally would indicate a larger amount of urine output. Choice C is incorrect as renal failure would typically present with other signs and symptoms. Choice D is incorrect as the presence of urinary retention does not necessarily mean the need for an indwelling catheter immediately.