HESI Fundamentals

HESI RN

1. During a home visit, an elderly female client who had a brain attack three months ago and can now ambulate with a quad cane is assessed by the nurse. Which assessment finding has the greatest implications for this client's care?

A. The husband, who is the caregiver, begins to weep when the nurse asks how he is doing.
B. The client tells the nurse that she does not have much of an appetite today.
C. The nurse notes that there are numerous scatter rugs throughout the house.
D. The client's pulse rate is 10 beats higher than it was at the last visit one week ago.

Correct answer: C

Rationale: The presence of numerous scatter rugs throughout the house poses a significant safety hazard to the client who is ambulating with a quad cane. These rugs increase the risk of tripping and falling, making it the most critical finding that needs immediate attention to prevent potential injuries and ensure the client's safety during ambulation.

2. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

A. Position the client on the right side of the bed in reverse Trendelenburg.
B. Fill the enema container with 1000 ml of warm water and 5 ml of castile soap.
C. Reposition the client in the Sims' position.
D. Raise the side rails on both sides of the bed and elevate the bed to waist level.

Correct answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

3. When assisting an older adult client in preparing to take a tub bath, which nursing action is most important?

A. Check the bath water temperature.
B. Shut the bathroom door.
C. Ensure that the client has voided.
D. Provide extra towels.

Correct answer: A

Rationale: The most crucial nursing action when assisting an older adult client with a tub bath is to check the bath water temperature. This step is essential to prevent burns from hot water or chilling from water that is too cold. Ensuring the water temperature is safe is a critical aspect of promoting the client's safety and comfort during the bathing process.

4. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:

A. Work on establishing rapport with the patient.
B. Use humor to lighten emotionally charged topics of discussion.
C. Empathize with the patient when the patient shares sad feelings.
D. Demonstrate respect when discussing emotionally charged topics.

Correct answer: D

Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.

5. When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

A. Remind the child to clean his genital area.
B. Defer perineal care due to the child's age.
C. Retract the foreskin gently to cleanse the penis.
D. Inquire about the reason for the child not being circumcised.

Correct answer: C

Rationale: The correct action when bathing an uncircumcised boy older than 3 years is to gently retract the foreskin to cleanse the penis. This is important to ensure proper hygiene and prevent the accumulation of bacteria that can lead to infections. It is not advisable to defer perineal care because of the child's age, as hygiene is crucial at any age. Asking the parents about the circumcision status may not be relevant during routine perineal care. Reminding the child to clean his genital area is not as effective as directly cleaning the area during bathing.

Similar Questions

When bathing an uncircumcised boy older than 3 years, which action should the nurse take?

While conducting an intake assessment of an adult male at a community mental health clinic, the nurse notes that his affect is flat, he responds to questions with short answers, and he reports problems with sleeping. He reports that his life partner recently died from pneumonia. Which action is most important for the nurse to implement?

A hospitalized client has had difficulty falling asleep for two nights and is becoming irritable and restless. Which action by the nurse is best?

When assessing a client with wrist restraints, the nurse observes that the fingers on the right hand are blue. What action should the nurse implement first?

A client is receiving total parenteral nutrition (TPN). Which assessment finding is most concerning to the nurse?

The client, who is newly diagnosed with arteriosclerosis and is obese, is being educated by the nurse on reducing the risk of a heart attack or stroke. Which health promotion brochure should the nurse provide to this client?

Access More Features

HESI RN Basic
$69.99/ 30 days

50,000 Questions with answers
All HESI courses Coverage
30 days access @ $69.99

HESI RN Premium
$149.99/ 90 days

50,000 Questions with answers
All HESI courses Coverage
30 days access @ $149.99

HESI RN

TestBanks

HESI RN