HESI RN
HESI Fundamentals Quizlet
1. When caring for a client with a chest tube, which intervention is most important?
- A. Keep the drainage system at chest level.
- B. Ensure that the chest tube is clamped at all times.
- C. Strip the chest tube every shift.
- D. Ensure that the chest tube is connected to a water-seal drainage system.
Correct answer: D
Rationale: The most crucial intervention when caring for a client with a chest tube is to ensure that the chest tube is connected to a water-seal drainage system (D). This system helps maintain proper lung expansion and prevents complications. Keeping the drainage system at chest level (A) is important to facilitate drainage, but not as critical as ensuring the connection to the drainage system. Clamping the chest tube (B) is unnecessary and can lead to serious issues. Stripping the chest tube (C) is an outdated practice and can cause harm rather than benefit.
2. A healthcare professional has a prescription to collect a 24-hour urine specimen from a client. Which of the following measures should the healthcare professional take during this procedure?
- A. Keeping the specimen chilled
- B. Saving the first urine specimen collected at the start time
- C. Discarding the last voided specimen at the end of the collection time
- D. Asking the client to void, discarding the specimen, and noting the start time
Correct answer: D
Rationale: The correct answer is asking the client to void, discarding the specimen, and noting the start time. During a 24-hour urine collection, the first voided urine is discarded to ensure the test starts with an empty bladder. The specimen should be kept chilled, not at room temperature, to prevent bacterial growth. The last voided specimen is not discarded because it contributes to the total volume collected, so choice C is incorrect. Discarding the specimen and noting the start time is essential for accurate results in a timed quantitative determination like a 24-hour urine collection.
3. The nurse is caring for a client with hypothyroidism. Which of the following clinical findings should the nurse expect?
- A. Tachycardia
- B. Weight loss
- C. Cold intolerance
- D. Diaphoresis
Correct answer: C
Rationale: Cold intolerance is a classic symptom of hypothyroidism. In hypothyroidism, the body's metabolic rate is decreased, leading to a decreased ability to regulate body temperature. This results in a feeling of being cold most of the time. Tachycardia (Choice A) is more commonly associated with hyperthyroidism, not hypothyroidism. Weight loss (Choice B) and diaphoresis (Choice D) are also more characteristic of hyperthyroidism, where there is an increased metabolic rate and excess heat production.
4. Which of the following is the most appropriate diet for a client during the acute phase of myocardial infarction?
- A. Liquids as desired.
- B. Small, easily digested meals.
- C. Three regular meals per day.
- D. Nothing by mouth.
Correct answer: B
Rationale: During the acute phase of myocardial infarction, it is recommended to provide small, easily digested meals for the client. This type of diet is better tolerated as it reduces the workload on the heart, allowing for easier digestion and absorption of nutrients. Choice A, 'Liquids as desired,' may not provide adequate nutrition and may not be well-balanced. Choice C, 'Three regular meals per day,' may be too heavy for the client's weakened condition. Choice D, 'Nothing by mouth,' is not appropriate as the client still requires essential nutrients for recovery.
5. A 66-year-old woman is retiring and will no longer have health insurance through her place of employment. Which agency should the client be referred to by the employee health nurse for health insurance needs?
- A. Woman, Infants, and Children program
- B. Medicaid
- C. Medicare
- D. Consolidated Omnibus Budget Reconciliation Act provision
Correct answer: C
Rationale: The correct answer is C: Medicare. Title XVII of the Social Security Act of 1965 created the Medicare Program to provide medical insurance for individuals who are 65 years or older, disabled, or have permanent kidney failure. Medicare is the appropriate agency to refer a 66-year-old woman who is retiring and losing her employment-based health insurance. Choice A, the Woman, Infants, and Children program, is not suitable for this scenario as it provides assistance for low-income pregnant women, breastfeeding women, and young children. Choice B, Medicaid, is a program that helps individuals with low income and resources cover medical costs, which may not be applicable to this woman's situation. Choice D, the Consolidated Omnibus Budget Reconciliation Act provision, known as COBRA, allows employees to continue their group health insurance coverage after leaving their job but may not be the best option for this woman in this case.