HESI RN
HESI Fundamentals Quizlet
1. When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?
- A. Confirm the finding by further assessing the client for jugular vein distention.
- B. Offer the client high-protein snacks between regularly scheduled mealtimes.
- C. Continue the planned nursing interventions to restore the client's fluid volume.
- D. Change the plan of care to include interventions for impaired skin integrity.
Correct answer: C
Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. This finding indicates dehydration and the need to restore the client's fluid volume. Therefore, the appropriate action for the nurse is to continue the planned nursing interventions aimed at addressing the fluid deficit. Choice A is incorrect as jugular vein distention is associated with fluid overload, not deficit. Choice B is incorrect as offering high-protein snacks does not directly address the fluid volume deficit. Choice D is incorrect as the priority is to address the fluid deficit before addressing skin integrity issues.
2. An adolescent client with meningococcal meningitis is receiving a continuous IV infusion of penicillin G. How many mL/hour should the nurse program the infusion pump to deliver?
- A. 83
- B. 85
- C. 87
- D. 90
Correct answer: A
Rationale: The correct answer is A: 83. The pharmacy provided the infusion at 10 million units per liter, which requires a rate of 83 mL/hour. To calculate this, multiply the dosage by the volume of the IV solution and divide by the concentration of the IV solution in million units: 10 million units per liter x 8.3 L = 83 mL/hour. Choices B, C, and D are incorrect as they do not align with the calculation based on the given information.
3. Expanded access to family planning through non-public delivery systems is facilitated by all of the following EXCEPT:
- A. By using the private sector and social marketing
- B. Community-based programs
- C. Information, Education, and Communication
- D. Key persons in the community
Correct answer: D
Rationale: Expanded access to family planning through non-public delivery systems involves utilizing various strategies to reach more people. Options A, B, and C are all effective methods for expanding access to family planning services. The involvement of key persons in the community is not a typical approach for non-public delivery systems. Key persons in the community may have influence but may not be directly involved in the delivery of family planning services, making option D the correct answer.
4. A client is diagnosed with tuberculosis and is placed on isoniazid (INH) and rifampin (Rifadin). The nurse should emphasize the importance of
- A. Daily use of a bronchodilator
- B. The importance of taking medication as prescribed
- C. Decreasing salt intake
- D. Avoidance of direct sunlight
Correct answer: B
Rationale: The correct answer is B: The importance of taking medication as prescribed. In the treatment of tuberculosis, adherence to the prescribed medication regimen is crucial to effectively manage the infection and prevent the development of drug resistance. Choices A, C, and D are incorrect because bronchodilators, salt intake, and sunlight exposure are not directly related to the treatment of tuberculosis with isoniazid and rifampin.
5. Which of the following hormone ratios is MOST likely to be increased in a patient with PCOS?
- A. Progesterone/estrogen
- B. LH/FSH
- C. FSH/LH
- D. Glucagon/insulin
Correct answer: B
Rationale: In patients with Polycystic Ovary Syndrome (PCOS), the LH/FSH ratio is most likely to be increased. This hormonal imbalance is a key characteristic of PCOS, where elevated LH levels relative to FSH contribute to the pathophysiology of the condition. Choice A, progesterone/estrogen ratio, is not typically a defining feature of PCOS. Choice C, FSH/LH ratio, is the reverse of what is commonly observed in PCOS. Choice D, glucagon/insulin ratio, is not directly related to the hormonal imbalances seen in PCOS.