HESI RN
HESI Maternity Test Bank
1. The nurse is caring for a one-year-old child following surgical correction of hypospadias. Which nursing action has the highest priority?
- A. Monitor urinary output
- B. Auscultate bowel sounds
- C. Observe appearance of stool
- D. Record percent of diet consumed
Correct answer: A
Rationale: In caring for a one-year-old child post hypospadias surgery, the highest priority action is to monitor urinary output. This is crucial to assess kidney function and ensure there are no complications following the surgical procedure. Auscultating bowel sounds, observing stool appearance, and recording diet consumption are important assessments too, but in this case, monitoring urinary output takes precedence due to the nature of the surgery and potential complications related to urinary function.
2. A nurse is providing care to a primigravida whose membranes spontaneously ruptured (ROM) 4 hours ago. Labor is to be induced. At the time of the ROM the vital signs were T-99.8 degrees F, P-84, R-20, BP-130/78, and fetal heart tones (FHT) 148 beats/min. Which assessment findings taken now may be an early indication that the client is developing a complication of labor?
- A. FHT 168 beats/min
- B. Temperature 100 degrees Fahrenheit
- C. Cervical dilation of 4 cm
- D. BP 138/88
Correct answer: A
Rationale: The correct answer is A. Fetal heart rate elevation can indicate distress, making it an early sign of labor complications. Choices B, C, and D are not the best answers in this scenario. Choice B, an elevated temperature, could indicate infection but is not a direct sign of labor complications. Choice C, cervical dilation of 4 cm, is a normal part of labor progression for a primigravida. Choice D, a blood pressure of 138/88, falls within normal limits and is not an early indication of labor complications.
3. Respect in reproductive health care involves:
- A. Talking to patients politely and managing their care compassionately and non-judgmentally.
- B. Ensuring that all patients sign a consent form.
- C. Ignoring patient requests for privacy.
- D. Disregarding patient concerns during care.
Correct answer: A
Rationale: Respect in reproductive health care entails treating patients with politeness, compassion, and without judgment. Choice A is the correct answer as it aligns with the principles of respect and patient-centered care. It is essential to communicate respectfully, show compassion, and address patients' needs without passing judgment. Choices B, C, and D are incorrect. Ensuring consent through a form is important but not the sole aspect of respect. Ignoring patient requests for privacy goes against patient rights, and disregarding patient concerns is contrary to providing comprehensive care.
4. What type of epithelium lines the vagina?
- A. Ciliated epithelium.
- B. Squamous epithelium.
- C. Columnar epithelium.
- D. Transitional epithelium.
Correct answer: B
Rationale: The correct answer is B: Squamous epithelium. The vagina is lined with non-keratinized stratified squamous epithelium. This type of epithelium provides protection against abrasion and pathogens. Choice A, Ciliated epithelium, is incorrect as ciliated epithelium is found in areas like the fallopian tubes to help move the egg towards the uterus. Choice C, Columnar epithelium, is incorrect as columnar epithelium is typically found in areas like the intestines. Choice D, Transitional epithelium, is incorrect as this type of epithelium is found in areas like the urinary bladder.
5. A client has just undergone insertion of a chest tube that is attached to a closed chest drainage system. Which action should the nurse plan to take in the care of this client?
- A. Assessing the client’s chest for crepitus every 24 hours
- B. Taping the connections between the chest tube and the drainage system
- C. Adding 20 mL of sterile water to the suction control chamber every shift
- D. Recording the volume of secretions in the drainage collection chamber every 24 hours
Correct answer: B
Rationale: The correct action for the nurse to take in caring for a client with a chest tube connected to a closed chest drainage system is to tape the connections between the chest tube and the drainage system. This is done to prevent accidental disconnection, ensuring the system functions properly. Assessing the client’s chest for crepitus should be done more frequently than once every 24 hours to monitor for any air leaks. Adding sterile water to the suction control chamber is not necessary every shift; it should be done as needed to maintain the appropriate water level. Recording the volume of secretions in the drainage collection chamber should be done more frequently than every 24 hours, with hourly monitoring during the first 24 hours after insertion and every 8 hours thereafter to assess for changes or complications.