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. When planning care for a client with an indwelling urinary catheter, which nursing diagnosis has the highest priority?
- A. Self-care deficit
- B. Functional incontinence
- C. Fluid volume deficit
- D. High risk for infection
Correct answer: D
Rationale: The highest priority nursing diagnosis when planning care for a client with an indwelling urinary catheter is 'High risk for infection.' Indwelling urinary catheters pose a significant risk of infection due to their direct contact with the urinary system. Preventing and managing infections is crucial in the care of these clients. Monitoring for signs of infection, following proper catheter care protocols, and maintaining aseptic technique during catheter maintenance are essential steps to prevent complications associated with catheter-related infections. Choices A, B, and C are not the highest priority because in this case, the immediate concern is the risk of infection associated with the presence of the urinary catheter. While self-care deficit, functional incontinence, and fluid volume deficit are important considerations in overall patient care, they are not as critical as preventing potentially serious infections related to the indwelling urinary catheter.
3. What action should be implemented to prevent the formation of a sacral ulcer for an immobile client?
- A. Maintain the client in a lateral position using protective wrist and vest restraints.
- B. Position the client prone with a small pillow below the diaphragm.
- C. Raise the head and knee gatch when lying in a supine position.
- D. Transfer the client to a wheelchair close to the nursing station for observation.
Correct answer: B
Rationale: Positioning the client prone with a small pillow below the diaphragm helps maintain proper alignment and provides optimal pressure relief over the sacral area, reducing the risk of developing a pressure ulcer. This position redistributes pressure away from bony prominences, such as the sacrum, which is crucial in preventing ulcer formation in immobile clients. Choice A is incorrect because using restraints can lead to further complications and does not address pressure relief. Choice C is incorrect as raising the head and knee gatch in a supine position does not directly alleviate pressure over the sacrum. Choice D is incorrect as transferring to a wheelchair does not address pressure relief or optimal positioning to prevent sacral ulcers.
4. Which instruction should be included in the discharge teaching plan for an adult client with hypernatremia?
- A. Monitor daily urine output volume
- B. Drink plenty of water whenever thirsty
- C. Use salt tablets for sodium content
- D. Review food labels for sodium content
Correct answer: D
Rationale: In hypernatremia, there is an excess of sodium in the blood. Reviewing food labels for sodium content is crucial as it helps the client identify and avoid high-sodium foods, which can contribute to elevated sodium levels. Monitoring urine output volume may be important for other conditions but is not directly related to managing hypernatremia. Drinking water whenever thirsty is generally good advice for staying hydrated but does not specifically address the issue of high sodium levels. Using salt tablets would worsen hypernatremia by further increasing sodium intake.
5. A client is admitted with a diagnosis of heart failure. Which dietary instruction should the nurse provide?
- A. Increase fluid intake to 3 liters per day.
- B. Limit sodium intake to 2 grams per day.
- C. Avoid foods high in potassium.
- D. Increase protein intake to promote healing.
Correct answer: B
Rationale: Limiting sodium intake to 2 grams per day (B) is a crucial dietary instruction for clients with heart failure. It helps manage fluid retention and reduces the workload on the heart. Excessive sodium can lead to fluid retention, worsening heart failure symptoms. Increasing fluid intake (A) can further exacerbate fluid overload in heart failure patients. Avoiding foods high in potassium (C) is not necessary unless the client has hyperkalemia; in heart failure, potassium restriction is not a primary dietary concern. Increasing protein intake (D) is not the priority for heart failure management; focusing on sodium restriction is more beneficial.
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