HESI RN
HESI Quizlet Fundamentals
1. The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove needle before discarding used syringes
- B. Wear gloves to dispose of the needle and syringe
- C. Don a face mask before administering the medication
- D. Wash hands before handling the needle and syringe
Correct answer: D
Rationale: Washing hands before handling needles and syringes is a crucial aspect of standard precautions to prevent infections. This practice helps reduce the risk of transferring microorganisms from the hands to the syringes and needles, thus promoting safety during medication administration.
2. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid eating green leafy vegetables.
- B. I should wear loose-fitting clothes to avoid pressure on my legs.
- C. I should avoid prolonged sitting or standing.
- D. I should continue taking my over-the-counter herbal supplements.
Correct answer: D
Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.
3. The nurse finds a client crying behind a locked bathroom door. The client will not open the door. Which action should the nurse implement first?
- A. Instruct an unlicensed assistive personnel (UAP) to stay and keep talking to the client.
- B. Sit quietly in the client's room until the client leaves the bathroom.
- C. Allow the client to cry alone and leave the client in the bathroom.
- D. Talk to the client and attempt to find out why the client is crying.
Correct answer: D
Rationale: When encountering a client in distress, the nurse's initial response should be to communicate with the client to assess the situation and provide support. By talking to the client and attempting to find out the reason for their distress, the nurse can offer appropriate assistance and ensure the client's well-being. This action prioritizes the client's emotional needs and helps establish a therapeutic relationship, which is essential in nursing care.
4. Twenty minutes after beginning a heat application, the client states that the heating pad no longer feels warm enough. What is the best response by the nurse?
- A. That means you have derived the maximum benefit, and the heat can be removed.
- B. Your blood vessels are becoming dilated and removing the heat from the site.
- C. We will increase the temperature by 5 degrees when the pad no longer feels warm.
- D. The body's receptors adapt over time as they are exposed to heat.
Correct answer: D
Rationale: Choice (D) describes thermal adaptation, which occurs 20 to 30 minutes after heat application. The body's receptors adjust to the constant heat exposure, leading to a decreased sensation of warmth. Choices (A) and (B) provide inaccurate information regarding the situation, while choice (C) is not physiologically sound and could potentially harm the client by increasing the temperature unnecessarily.
5. When caring for a client in hemorrhagic shock, how should the nurse position the client?
- A. Flat in bed with legs elevated.
- B. Flat in bed.
- C. Trendelenburg position.
- D. Semi-Fowler's position.
Correct answer: A
Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.
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