HESI RN
HESI Fundamentals
1. What is the most important instruction for the nurse to provide to a 65-year-old client who attends an adult daycare program, is wheelchair-mobile, and has redness in the sacral area?
- A. Take a vitamin supplement tablet once a day.
- B. Change positions in the chair at least every hour.
- C. Increase daily intake of water or other oral fluids.
- D. Purchase a newer model wheelchair.
Correct answer: B
Rationale: For a client with redness in the sacral area, the most critical instruction is to change positions in the chair at least every hour. This is crucial to prevent pressure ulcers, which can develop due to prolonged pressure on the skin and underlying tissues. Regular position changes help relieve pressure on vulnerable areas, promoting circulation and reducing the risk of skin breakdown and pressure ulcer formation.
2. A client with a diagnosis of hyperthyroidism is being discharged. Which instruction should the nurse include in the discharge teaching?
- A. Avoid foods high in iodine.
- B. Take your medication with meals.
- C. Monitor your weight daily.
- D. Decrease your daily fluid intake.
Correct answer: A
Rationale: The correct answer is A: 'Avoid foods high in iodine.' Clients with hyperthyroidism should avoid foods high in iodine to prevent exacerbation of their condition. Iodine is an essential component in thyroid hormone production, and excessive iodine intake can worsen hyperthyroidism symptoms. Taking medication with meals (B) can interfere with the absorption of certain thyroid medications. Monitoring weight daily (C) is more relevant for conditions that may lead to weight changes like hypothyroidism. Decreasing fluid intake (D) is not a standard recommendation for hyperthyroidism unless specifically indicated by the healthcare provider.
3. A client is receiving external radiation therapy for lung cancer. Which intervention is most important for the nurse to include in the client's plan of care?
- A. Encourage the client to use sunscreen when outdoors.
- B. Apply a heating pad to the radiation site.
- C. Instruct the client to avoid using deodorant on the skin near the radiation site.
- D. Advise the client to increase intake of green leafy vegetables.
Correct answer: C
Rationale: Instructing the client to avoid using deodorant on the skin near the radiation site (C) is crucial to prevent skin irritation and potential adverse reactions during external radiation therapy. Sunscreen (A), heating pad (B), and dietary changes (D) are less pertinent in this situation.
4. The nurse observes an unlicensed assistive personnel (UAP) taking a client's blood pressure with a cuff that is too small, but the blood pressure reading obtained is within the client's usual range. What action is most important for the nurse to implement?
- A. Tell the UAP to use a larger cuff at the next scheduled assessment.
- B. Reassess the client's blood pressure using a larger cuff.
- C. Have the unit educator review this procedure with the UAPs.
- D. Teach the UAP the correct technique for assessing blood pressure.
Correct answer: B
Rationale: The most important action is to ensure that an accurate BP reading is obtained. The nurse should reassess the blood pressure with the correct size cuff (B) to obtain an accurate reading. Postponing reassessment (A) could lead to inaccurate results. While (C and D) are important actions for education and quality improvement, they are not as critical as obtaining an accurate blood pressure reading in this situation.
5. A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?
- A. Blood glucose level of 150 mg/dL.
- B. Blood pressure of 110/70 mm Hg.
- C. Serum albumin level of 3.5 g/dL.
- D. The client's temperature is 100.4°F (38°C).
Correct answer: D
Rationale: A temperature of 100.4°F (38°C) (D) is the most concerning finding for a client receiving total parenteral nutrition (TPN) as it may indicate an infection, which poses a significant risk. Monitoring blood glucose level (A), blood pressure (B), and serum albumin (C) are also important, but an elevated temperature suggests a potential serious complication that requires immediate attention.
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