HESI RN
HESI Fundamentals
1. Which client care task requires the nurse to wear barrier gloves as mandated by the Standard Precautions protocol?
- A. Removing the empty food tray from a client with a urinary catheter.
- B. Washing and combing the hair of a client with a fractured leg in traction.
- C. Administering oral medications to a cooperative client with a wound infection.
- D. Emptying the urinary catheter drainage bag for a client with Alzheimer's disease.
Correct answer: D
Rationale: The correct answer is D because emptying a urinary catheter drainage bag exposes the nurse to body fluids, necessitating the use of barrier gloves as per Standard Precautions to prevent potential infection transmission.
2. At 0100 on a male client’s second postoperative night, the client states he is unable to sleep and plans to read until feeling sleepy. What action should the nurse implement?
- A. Leave the room and close the door to the client’s room
- B. Assess the appearance of the client’s surgical dressing
- C. Bring the client a prescribed PRN sedative-hypnotic
- D. Discuss symptoms of sleep deprivation with the client
Correct answer: A
Rationale: The client has expressed a plan to read until feeling sleepy, indicating that he is managing his inability to sleep. In this situation, it is best for the nurse to respect the client's autonomy and leave the room, providing privacy and an opportunity for the client to relax and hopefully fall asleep. Closing the door can also help create a quiet environment conducive to rest.
3. A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?
- A. Insert the needle at a 90-degree angle for subQ injections
- B. Aspirate for blood return before injecting the medication
- C. Pinch the skin before inserting the needle
- D. Massage the site after administering the injection
Correct answer: C
Rationale: Pinching the skin before inserting the needle is essential in elevating the subcutaneous tissue away from the muscle. This technique ensures that the medication is administered into the correct tissue layer, promoting proper absorption and decreasing the risk of injecting into muscle tissue.
4. When making the bed of a client who needs a bed cradle, which action should the nurse include?
- A. Teach the client to call for help before getting out of bed.
- B. Keep both the upper and lower side rails in a raised position.
- C. Keep the bed in the lowest position while changing the sheets.
- D. Drape the top sheet and covers loosely over the bed cradle.
Correct answer: D
Rationale: A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. This helps in maintaining the proper positioning and function of the bed cradle to ensure the client's comfort and safety during bed making.
5. When assisting a client with right-sided hemiplegia to get into a wheelchair, how should the nurse position the wheelchair?
- A. On the left side of the bed facing the foot of the bed.
- B. On the right side of the bed facing the head of the bed.
- C. Perpendicular to the bed on the right side.
- D. Facing the bed on the left side of the bed.
Correct answer: A
Rationale: Positioning the wheelchair on the left side of the bed facing the foot of the bed is the correct approach when assisting a client with right-sided hemiplegia. Placing the wheelchair on the left side allows the client to stand on their unaffected foot and pivot to sit down safely. This positioning facilitates a smoother transfer and helps maintain the client's stability during the process. Choice B is incorrect because positioning the wheelchair on the right side facing the head of the bed would make it challenging for the client to transfer due to their right-sided hemiplegia. Choice C is incorrect as placing the wheelchair perpendicular to the bed on the right side may not provide the necessary space and angle for a safe transfer. Choice D is incorrect as facing the bed on the left side of the bed does not provide the optimal position for the client to transfer from the bed to the wheelchair effectively.
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