HESI RN
HESI Fundamentals
1. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record
- B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is a legal obligation of the examining nurse
Correct answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.
2. After surgery, a patient has decreased cardiac output. What is a likely observation by the nurse?
- A. Decreased urine output
- B. Increased urine output
- C. Flushing of the skin
- D. Hyperventilation
Correct answer: A
Rationale: A decrease in cardiac output can lead to decreased blood flow to the kidneys, resulting in decreased urine output. The kidneys rely on adequate blood supply to filter waste and produce urine. Therefore, a decreased urine output is a common observation when cardiac output is reduced. Choices B, C, and D are incorrect. Increased urine output is not typically associated with decreased cardiac output; flushing of the skin is more related to vasodilation, and hyperventilation is not directly linked to decreased cardiac output.
3. After surgery, a client who had a colostomy says 'I know the doctor did not really do a colostomy'. The nurse understands that the client is in an early stage of adjustment to the diagnosis or surgery. What nursing action is indicated at this time?
- A. Agree with the client until they are ready to accept the colostomy.
- B. Say 'It must be difficult to have this kind of surgery'.
- C. Force the client to look at their colostomy.
- D. Ask the surgeon to explain the surgery to the client.
Correct answer: B
Rationale: Acknowledging the client's feelings with empathy is essential in the early stage of adjustment to a colostomy surgery. By saying 'It must be difficult to have this kind of surgery,' the nurse validates the client's emotions and opens up a channel for further communication. Choice A is incorrect because agreeing with the client's denial is not therapeutic and may hinder acceptance. Choice C is inappropriate as it disregards the client's emotional state and autonomy. Choice D involves the surgeon and is not the nurse's role in addressing the client's emotional needs.
4. Mr. Landon is scheduled to undergo a tracheostomy. Which nursing action is essential during tracheal suctioning?
- A. Using a water-soluble lubricant.
- B. Administering 100% oxygen before and after suctioning.
- C. Ensuring that the suction catheter is open during insertion.
- D. Assisting the client to assume a semi-Fowler's position during suctioning.
Correct answer: B
Rationale: Administering 100% oxygen before and after suctioning is crucial to prevent hypoxia, which can occur during tracheal suctioning. Hypoxia can lead to serious complications, making the provision of oxygen essential in maintaining adequate oxygenation levels for the patient undergoing tracheal suctioning. Choice A is incorrect because using a water-soluble lubricant is not directly related to the essential nursing action during tracheal suctioning. Choice C is incorrect as ensuring that the suction catheter is open during insertion is a basic requirement and not the essential action for oxygenation. Choice D is incorrect because assisting the client to assume a semi-Fowler's position is beneficial for comfort and airway alignment but is not as crucial as administering oxygen to prevent hypoxia.
5. 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.
Similar Questions
Access More Features
HESI RN Basic
$69.99/ 30 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access
HESI RN Premium
$149.99/ 90 days
- 5,000 Questions with answers
- All HESI courses Coverage
- 30 days access