HESI RN
HESI Quizlet Fundamentals
1. When measuring vital signs, the healthcare provider observes that a client is using accessory neck muscles during respirations. What follow-up action should the healthcare provider take first?
- A. Determine pulse pressure
- B. Auscultate heart sounds
- C. Measure oxygen saturation
- D. Check for neck vein distention
Correct answer: C
Rationale: Observing a client using accessory neck muscles during respiration indicates respiratory distress. The priority action should be to measure oxygen saturation to assess the adequacy of oxygenation. This intervention provides crucial information about the client's respiratory status and helps guide further assessment and interventions.
2. A child with acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement?
- A. Obtain a specimen for blood cultures.
- B. Assess the CBC.
- C. Monitor the oral temperature every hour.
- D. Administer acetaminophen as prescribed.
Correct answer: A
Rationale: Obtaining a specimen for blood cultures is crucial in this situation as it helps identify the source of infection, if present, and guide appropriate treatment. This is important in a child with leukemia receiving chemotherapy to prevent potential complications and ensure timely intervention. Assessing the CBC may provide overall information on the child's condition but may not specifically identify a potential infection. Monitoring the oral temperature is important but obtaining blood cultures takes precedence in this scenario. Administering acetaminophen can help reduce fever but does not address the need to identify a possible infection source.
3. Which of the following options correctly lists biology's hierarchical organizational system?
- A. Phylum, Kingdom, Class, Family, Order, Species, Genus
- B. Kingdom, Phylum, Class, Order, Family, Genus, Species
- C. Genus, Order, Kingdom, Class, Phylum, Species, Family
- D. Class, Phylum, Kingdom, Genus, Order, Family, Species
Correct answer: B
Rationale: The correct hierarchical organizational system in biology is Kingdom, Phylum, Class, Order, Family, Genus, and Species. This follows the mnemonic 'King Phillip Came Over For Good Soup.' Choice A is incorrect as it does not follow the correct hierarchical order. Choice C is incorrect as it starts with Genus, which is more specific and should come after Family. Choice D is incorrect as it does not follow the correct hierarchical order.
4. A teenager who has lost 20 pounds in the last three months is admitted to the hospital with hypotension and tachycardia. The client reports irregular menses and hair loss. Which intervention is most important for the nurse to include in the client’s plan of care?
- A. Initiate caloric and nutritional therapy.
- B. Implement behavioral modification therapy.
- C. Evaluate the client for low self-esteem.
- D. Record daily weights and graph trends.
Correct answer: A
Rationale: The client presents with evidence of anorexia nervosa resulting from self-starvation, which is a life-threatening condition. Providing nutrition and calories is the priority intervention so that the risk of electrolyte imbalance and severe dehydration can be reduced. Behavioral modification therapy (Choice B) may be beneficial in the long term but is not the priority in this acute situation. Evaluating for low self-esteem (Choice C) may be part of the nursing assessment but does not address the immediate life-threatening issues. Recording daily weights and graphing trends (Choice D) is important for monitoring progress but does not address the critical need for nutritional therapy in this case.
5. The healthcare professional is assessing a client with a diagnosis of peripheral arterial disease (PAD). Which assessment finding is most indicative of this condition?
- A. Dependent rubor.
- B. Absence of hair on the lower legs.
- C. Shiny, thin skin on the legs.
- D. Pain in the legs when walking.
Correct answer: D
Rationale: Pain in the legs when walking (D), known as intermittent claudication, is most indicative of peripheral arterial disease (PAD). While dependent rubor (A), absence of hair (B), and shiny, thin skin (C) are also associated with PAD, they are less specific than intermittent claudication. Intermittent claudication is a hallmark symptom of PAD caused by inadequate blood flow to the legs during exercise, resulting in pain that resolves with rest.