HESI RN
HESI Fundamentals Quizlet
1. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
- A. Remove identifying information of the clients who participated
- B. Recall that authored content may be legally discoverable
- C. Share material from credible, peer-reviewed sources only
- D. Respect all copyright laws when adding website content
Correct answer: A
Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.
2. Which group of the population does the Maternal nutrition component of IRH improve?
- A. Women and adolescent girls
- B. Pregnant women alone
- C. Pregnant women and all children under five
- D. All adolescents
Correct answer: A
Rationale: The correct answer is A: Women and adolescent girls. Maternal nutrition programs typically target women of reproductive age and adolescent girls to improve their health outcomes. Option B is incorrect because maternal nutrition initiatives extend beyond just pregnant women. Option C is incorrect because the focus is not on all children under five but specifically on women and adolescent girls. Option D is incorrect because the program does not target all adolescents, but rather women and adolescent girls.
3. The nurse is caring for a client who is 2 days post-op following an abdominal surgery. The client reports feeling something 'give way' in the incision site and there is a small amount of bowel protruding from the wound. What action should the nurse take first?
- A. Apply a sterile saline dressing to the wound
- B. Notify the healthcare provider
- C. Administer pain medication
- D. Cover the wound with an abdominal binder
Correct answer: A
Rationale: In this situation, the priority action for the nurse is to apply a sterile saline dressing to the wound. This helps prevent infection and keeps the wound moist, which is crucial in promoting healing and preventing further complications. Option B, notifying the healthcare provider, is important but should come after addressing the wound. Administering pain medication (Option C) may be necessary but is not the first action to take in this emergency situation. Covering the wound with an abdominal binder (Option D) is not appropriate and may cause further harm by applying pressure to the protruding bowel.
4. The provider has ordered Kayexalate and sorbitol to be administered to a patient. The nurse caring for this patient would expect which serum electrolyte values prior to administration of this therapy?
- A. Sodium 125 mEq/L and potassium 2.5 mEq/L
- B. Sodium 150 mEq/L and potassium 3.6 mEq/L
- C. Sodium 135 mEq/L and potassium 6.9 mEq/L
- D. Sodium 148 mEq/L and potassium 5.5 mEq/L
Correct answer: C
Rationale: Severe hyperkalemia, with a potassium level of 6.9 mEq/L, requires aggressive treatment with Kayexalate and sorbitol to increase the body’s excretion of potassium. The normal range for serum potassium is 3.5 to 5.5 mEq/L, so patients with the other potassium levels would not be treated aggressively or would need potassium supplementation. Therefore, option C (Sodium 135 mEq/L and potassium 6.9 mEq/L) is the correct choice as it indicates severe hyperkalemia warranting the administration of Kayexalate and sorbitol. Options A, B, and D have either potassium levels within normal limits, which would not necessitate this aggressive treatment, or potassium levels that are lower than what would typically prompt the need for Kayexalate and sorbitol.
5. A client with type 1 DM is taught to take NPH and regular insulin every morning. The nurse should provide which instructions to the client?
- A. Take the NPH insulin first, then the regular insulin.
- B. Take the regular insulin first, then the NPH insulin.
- C. It does not matter which insulin is drawn up first.
- D. Contact the healthcare provider if the order for insulin is unclear.
Correct answer: B
Rationale: The correct answer is to take the regular insulin first, then the NPH insulin. Regular insulin should be drawn up before NPH insulin to prevent contamination of the regular insulin vial with the longer-acting insulin. Choice A is incorrect as it suggests taking the NPH insulin first, which is not the recommended practice. Choice C is incorrect because the order of drawing up insulin does matter to prevent contamination. Choice D is not the most appropriate action in this scenario, as the nurse should provide clear instructions to the client based on best practices.