HESI RN
HESI Fundamentals
1. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?
- A. Provide an interpreter to convey the meaning of words and messages in translation
- B. Commend the client for her patience during a long wait in the admission process
- C. Arrange for the hospital chaplain to visit the client during her hospital stay
- D. Rely on cultural norms as the basis for providing healthcare for this client
Correct answer: D
Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.
2. The client is reviewing the signed operative consent with a nurse, who is admitted for the removal of a lipoma on the left leg. The client states that the consent form should say the removal of a lipoma on the right leg. Which intervention should the nurse implement?
- A. Notify the surgical team of the client’s confusion
- B. Have the client sign a new surgical consent
- C. Add the correct leg information to the consent form
- D. Inform the surgeon about the client’s concern
Correct answer: D
Rationale: In this scenario, the nurse should inform the surgeon about the client’s concern immediately. This is important to ensure that the correct procedure is performed on the intended leg. Communication with the surgeon is crucial to address any discrepancies in the consent form and prevent errors during the surgical procedure. Having the surgeon clarify and correct the consent form is essential to maintain patient safety and uphold the principles of informed consent.
3. What is the main purpose of the working phase of the nurse-patient relationship?
- A. Establish a formal or informal contract that addresses the patient's problems.
- B. Implement nursing interventions that are designed to achieve expected patient outcomes.
- C. Develop rapport and trust so the patient feels supported, and the initial plan can be identified.
- D. Clearly identify the role of the nurse and establish the parameters of the professional relationship.
Correct answer: B
Rationale: The main purpose of the working phase in the nurse-patient relationship is to implement nursing interventions that are specifically tailored to achieve the expected patient outcomes. During this phase, the nurse actively works with the patient to put the care plan into action and make progress towards reaching the desired health goals. It involves the application of therapeutic communication, problem-solving, and interventions to address the patient's needs. Establishing rapport and trust is typically done in the orientation phase, while defining roles and boundaries usually occurs in the introductory phase of the relationship. Choices A, C, and D are incorrect as they describe activities more aligned with other phases of the nurse-patient relationship, such as orientation and introductory phases.
4. A female client with chronic back pain has been taking muscle relaxants and analgesics to manage the discomfort, but is now experiencing an acute episode of pain that is not relieved by this medication regimen. The client tells the nurse that she does not want to have back surgery for a herniated intervertebral disk, and reports that she has found acupuncture effective in resolving past acute episodes. Which response is best for the nurse to provide?
- A. Surgery removes the disk and is the only treatment that can totally resolve the pain
- B. The medication regimen you previously used should be re-evaluated for dose adjustment
- C. Massage and hot pack treatments are less invasive and can provide temporary relief
- D. Acupuncture is a complementary therapy that is often effective for management of pain
Correct answer: D
Rationale: Acknowledging the effectiveness of acupuncture is important, as the client has reported its success in managing her pain previously.
5. A client with frequent urinary tract infections (UTIs) asks the nurse about drinking juice daily to prevent future UTIs. Which response is best for the nurse to provide?
- A. Orange juice has vitamin C, which deters bacterial growth.
- B. Apple juice is the most useful in acidifying the urine.
- C. Cranberry juice stops pathogens' adherence to the bladder.
- D. Grapefruit juice increases the absorption of most antibiotics.
Correct answer: C
Rationale: Cranberry juice is known for its ability to prevent urinary tract infections by reducing the adherence of Escherichia coli bacteria to the cells within the bladder. This property helps in maintaining urinary tract health and preventing recurrent UTIs. Choices A, B, and D are incorrect because while vitamin C in orange juice may have some benefits, it is not specifically known for deterring bacterial growth in the urinary tract. Apple juice does not significantly impact urine acidity, and grapefruit juice does not enhance antibiotic absorption, making them less effective choices for preventing UTIs compared to cranberry juice.
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