HESI RN
HESI Quizlet Fundamentals
1. When taking a client's blood pressure, the healthcare professional is unable to distinguish the point at which the first sound was heard. What is the best action for the healthcare professional to take?
- A. Deflate the cuff completely and immediately reattempt the reading.
- B. Reinflate the cuff completely and leave it inflated for 90 to 110 seconds before taking the second reading.
- C. Deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading.
- D. Document the exact level visualized on the sphygmomanometer where the first fluctuation was seen.
Correct answer: C
Rationale: The correct action when unable to distinguish the point of the first sound during blood pressure measurement is to deflate the cuff to zero and wait 30 to 60 seconds before reattempting the reading. This allows blood flow to return to the extremity, ensuring a more accurate reading the second time. It is important to ensure that the cuff is fully deflated and the appropriate wait time is given to obtain an accurate blood pressure measurement.
2. A client with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 4 liters per minute via nasal cannula. The client becomes lethargic and confused. What action should the nurse take first?
- A. Decrease the oxygen flow rate
- B. Increase the oxygen flow rate
- C. Encourage the client to cough and deep breathe
- D. Monitor the client's oxygen saturation level
Correct answer: A
Rationale: In this scenario, the priority action for the nurse is to decrease the oxygen flow rate. Clients with COPD are sensitive to high levels of oxygen and can develop oxygen toxicity, leading to symptoms like lethargy and confusion. Decreasing the oxygen flow rate helps prevent this complication. Increasing the oxygen flow rate would worsen the client's condition. Encouraging coughing and deep breathing may not address the immediate issue of oxygen toxicity. While monitoring the client's oxygen saturation level is important, taking action to address the oxygen toxicity by decreasing the flow rate is the priority in this situation.
3. During a home visit, the nurse observes an elderly client with disabilities slip and fall. What action should the nurse take first?
- A. provide the client with 4 ounces of orange juice
- B. call 911 to summon emergency assistance
- C. check the client for lacerations or fractures
- D. assess the client's blood sugar level
Correct answer: C
Rationale: The correct action for the nurse to take first after an elderly client with disabilities slips and falls is to check the client for lacerations or fractures. This is crucial to assess the extent of injuries and provide appropriate medical attention promptly. Option A, providing orange juice, is not a priority in this situation and does not address the potential injuries. While calling 911 (Option B) may be necessary, assessing for immediate injuries takes precedence. Assessing the client's blood sugar level (Option D) is not the immediate priority after a fall unless there is a specific indication or suspicion of hypoglycemia.
4. A mother who is breastfeeding her baby receives instructions from the nurse. Which instruction is most effective to prevent nipple soreness?
- A. Wear a cotton bra.
- B. Increase nursing time gradually.
- C. Correctly place the infant on the breast.
- D. Manually express a small amount of milk before nursing.
Correct answer: C
Rationale: The most effective instruction to prevent nipple soreness when breastfeeding is to correctly place the infant on the breast. Proper latch-on techniques ensure that the baby is properly positioned, reducing the risk of nipple soreness. When the baby is positioned correctly, they can nurse effectively without causing discomfort to the mother.
5. After a client delivered vaginally 2 days ago, what information should you share with her if she wants to resume using her diaphragm for birth control?
- A. The diaphragm is the most effective form of contraception.
- B. The diaphragm must be refitted after childbirth.
- C. Vaseline lubricant should be used when inserting the diaphragm.
- D. The diaphragm should be inserted 2 to 4 hours before intercourse.
Correct answer: B
Rationale: After childbirth, the diaphragm must be refitted to ensure a proper fit and effectiveness. Changes in the body post-delivery can affect the fit of the diaphragm, making it necessary to get refitted. Choice A is incorrect because while the diaphragm can be effective, it is not the most effective form of contraception. Choice C is incorrect because oil-based lubricants like Vaseline can damage latex diaphragms. Choice D is incorrect because the diaphragm should be inserted no more than 2 hours before intercourse, not 2 to 4 hours.