HESI RN
HESI Quizlet Fundamentals
1. The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.
2. Binary fission is a type of asexual reproduction. Which of the following occurs during the binary fission process?
- A. The chromosomes bind to the plasma membrane
- B. The chromosomes attach to the spindle formed along the axis
- C. The chromosomes gather in the center of the cell
- D. The chromosomes begin to separate
Correct answer: A
Rationale: The correct answer is A. In binary fission, the chromosomes bind to the plasma membrane before the cell splits into two. This initial step ensures that each daughter cell receives a complete set of genetic material. Choice B is incorrect because the spindle apparatus is characteristic of eukaryotic cell division (mitosis), not prokaryotic binary fission. Choice C is incorrect as chromosomes do not necessarily gather in the center of the cell during binary fission. Choice D is incorrect because the chromosomes do not begin to separate in binary fission; they replicate and then move to opposite ends of the cell before division.
3. The parents of a 15-month-old boy tell the nurse that they are concerned because their son brings his spoon to his mouth but does not turn it over. What action should the nurse implement first?
- A. Discuss the possibility of a referral to a specialist
- B. Question the parents about their concern
- C. Advise the parents on proper spoon handling techniques for the child
- D. Recommend extending mealtimes to allow the child to finish eating
Correct answer: B
Rationale: The initial action for the nurse is to question the parents about their concerns. By doing so, the nurse can gather more information to understand the situation better. This helps in determining if the child's behavior is within normal development or if further action or referrals are necessary. Choice A is incorrect as it jumps to a specialist referral without fully assessing the situation first. Choice C is also incorrect because assuming the parents need advice on proper spoon handling techniques may not be the case. Choice D is incorrect as it does not address the core concern raised by the parents.
4. In a client with congestive heart failure, the nurse would be correct in withholding a dose of digoxin without specific instruction from the healthcare provider if the client's
- A. serum digoxin level is 1.5 ng/mL.
- B. blood pressure is 104/68 mmHg.
- C. serum potassium level is 3 mEq/L.
- D. apical pulse is 68/min.
Correct answer: C
Rationale: The correct answer is C. Hypokalemia can precipitate digitalis toxicity in individuals on digoxin, increasing the risk of dangerous dysrhythmias. A serum potassium level of 3 mEq/L is below the normal range (3.5 to 5.5 mEq/L) and indicates hypokalemia, which can potentiate the effects of digoxin. Choices A, B, and D are not directly related to the potential for digitalis toxicity. Serum digoxin level of 1.5 ng/mL is within the therapeutic range, blood pressure of 104/68 mmHg is not a contraindication for administering digoxin, and an apical pulse of 68/min is within the normal range and not a reason to withhold digoxin.
5. A client has a chest tube in place following a left lower lobectomy inserted after a stab wound to the chest. When repositioning the client, the nurse notices 200 cc of dark, red fluid flows into the collection chamber of the chest drain. What is the most appropriate nursing action?
- A. Clamp the chest tube
- B. Call the surgeon immediately
- C. Prepare for blood transfusion
- D. Continue to monitor the rate of drainage
Correct answer: D
Rationale: In this scenario, the most appropriate nursing action is to continue to monitor the rate of drainage. Clamping the chest tube is not recommended as it can lead to a tension pneumothorax. Calling the surgeon immediately may not be necessary at this point unless the drainage rate significantly increases or other concerning symptoms develop. Preparing for a blood transfusion is premature without further assessment and monitoring of the client's condition. Monitoring the rate of drainage allows the nurse to assess for any potential complications and ensure that the drainage amount is within expected limits.