HESI RN
HESI Fundamentals Quizlet
1. The client has received a new diagnosis of heart failure, and the nurse is providing dietary management education. Which instruction should the nurse include?
- A. Increase intake of foods high in potassium.
- B. Avoid foods high in sodium.
- C. Limit fluid intake to 1.5 liters per day.
- D. Increase intake of foods high in vitamin K.
Correct answer: B
Rationale: Avoiding foods high in sodium (choice B) is essential for clients with heart failure to prevent fluid retention and decrease the strain on the heart. High sodium intake can lead to fluid buildup, exacerbating heart failure symptoms. Increasing potassium intake (choice A) can be harmful in heart failure if not monitored closely as it can affect heart rhythm. Limiting fluid intake (choice C) may be necessary in some cases, but the specific amount should be individualized based on the client's condition. Increasing vitamin K intake (choice D) is not a primary concern in heart failure management and is more relevant for clients on anticoagulants to manage blood clotting.
2. The nurse plans to assist a male client out of bed for the first time since his surgery yesterday. His wife objects and tells the nurse to get out of the room because her husband is too ill to get out of bed. What should the nurse do first?
- A. Administer nasal oxygen at a rate of 5 L/min
- B. Help the client to lie back down in the bed
- C. Quickly pivot the client to the chair and elevate the legs
- D. Check the client’s blood pressure and pulse
Correct answer: D
Rationale: Before assisting the client out of bed, the nurse should first assess the client's blood pressure and pulse. This assessment is crucial to determine the client's physiological stability and readiness for ambulation. It ensures the client's safety during the transfer and helps prevent any potential complications that may arise from getting out of bed. Administering oxygen, lying the client back down, or quickly moving the client to a chair without assessing vital signs can compromise the client's safety and may lead to adverse outcomes.
3. The client with a below-the-knee amputation is being taught about proper care of the residual limb. The most important point to emphasize would be
- A. Wrap the stump with an elastic bandage to prevent swelling
- B. Keep the skin on the stump clean and dry
- C. Use alcohol to cleanse the stump daily
- D. Apply moisturizing lotion to the stump daily
Correct answer: B
Rationale: The correct answer is B: Keep the skin on the stump clean and dry. This is crucial for preventing infection and promoting healing of the residual limb. Wrapping the stump with an elastic bandage can constrict blood flow and cause issues. Using alcohol to cleanse the stump daily can be too harsh and drying for the skin, leading to irritation. Applying moisturizing lotion daily is not as essential as keeping the skin clean and dry to prevent complications.
4. Which of the following charges could be filed if consent was not obtained before the surgery?
- A. False imprisonment
- B. Libel
- C. Battery
- D. Malpractice
Correct answer: C
Rationale: The correct answer is C: Battery. Performing surgery without obtaining consent is considered battery, as it involves intentional harmful or offensive contact without consent. False imprisonment (choice A) involves unlawful restraint or restriction of a person's freedom of movement, which is not applicable in this scenario. Libel (choice B) refers to written defamation that damages a person's reputation, which is not related to lack of consent in surgery. Malpractice (choice D) pertains to professional negligence or failure to meet a standard of care, which is a separate issue from obtaining consent for surgery.
5. An adult female client has undergone a routine health screening in the clinic. Which of the following values indicates to the nurse who receives the report of the client’s laboratory work that the client’s hematocrit is normal?
- A. 10%
- B. 22%
- C. 30%
- D. 43%
Correct answer: D
Rationale: The normal hematocrit for an adult female client ranges from 35% to 47%. A hematocrit value of 43% falls within this normal range, indicating normal levels of red blood cells. Choices A, B, and C are low hematocrit values and are considered below the normal range for adult females, signifying potential anemia or other health issues.