HESI RN
HESI Quizlet Fundamentals
1. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
- A. That means you have derived the maximum benefit, and the heat can be removed.
- B. Your blood vessels are becoming dilated and removing the heat from the site.
- C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
- D. The body's receptors adapt over time as they are exposed to heat.
Correct answer: D
Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.
2. A mental health worker is caring for a client with escalating aggressive behavior. Which action by the mental health worker warrants immediate intervention by the RN?
- A. Attempting to physically restrain the client.
- B. Remaining at a distance of 4 feet from the client.
- C. Telling the client to go to the quiet area of the unit.
- D. Using a loud voice to communicate with the client.
Correct answer: A
Rationale: Attempting to physically restrain the client without proper protocol and preparation can escalate the situation. This can lead to increased agitation and aggression in the client, potentially putting both the client and the mental health worker at risk. Remaining at a distance, directing the client to a quiet area, or using a loud voice are all strategies that can be used to de-escalate the situation and ensure safety without resorting to physical intervention. Therefore, the immediate intervention is needed when the mental health worker attempts to physically restrain the client. Option B, remaining at a distance, is a safe practice to ensure personal safety. Option C, directing the client to a quiet area, is a de-escalation technique to create a calmer environment. Option D, using a loud voice, may be necessary to establish boundaries and ensure the client can hear instructions clearly.
3. The nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD). Which intervention is most important to promote effective breathing?
- A. Encourage diaphragmatic breathing
- B. Increase the client's oxygen flow rate
- C. Have the client perform range of motion exercises
- D. Place the client in a supine position
Correct answer: A
Rationale: Encouraging diaphragmatic breathing is crucial in clients with COPD as it helps improve lung expansion and oxygen exchange, promoting more effective breathing. This intervention aids in reducing dyspnea and enhancing ventilation. Increasing the client's oxygen flow rate may not be appropriate and can potentially worsen hypercapnia in individuals with COPD. Performing range of motion exercises and placing the client in a supine position do not directly address the breathing difficulties associated with COPD exacerbation.
4. What must first occur before a cell can be divided to grow, develop, and reproduce organisms?
- A. RNA replication
- B. DNA replication
- C. Gene replication
- D. Chromosome replication
Correct answer: B
Rationale: The correct answer is B: DNA replication. Before a cell can divide to grow, develop, and reproduce organisms, DNA replication must occur. This process ensures that each daughter cell receives an identical set of genetic information. Choices A, C, and D are incorrect because while RNA, genes, and chromosomes are essential components of cell division, DNA replication is the specific process that must first occur to ensure accurate transmission of genetic material.
5. A nurse is planning care for a client who is newly diagnosed with diabetes mellitus. Which instruction should the nurse include in this client’s teaching plan?
- A. Avoid all forms of sugar
- B. Check blood glucose levels once a week
- C. Rotate insulin injection sites
- D. Monitor urine ketone levels
Correct answer: C
Rationale: Rotating insulin injection sites prevents lipodystrophy and ensures proper insulin absorption.