HESI RN
HESI Fundamentals
1. A client is scheduled for a colonoscopy. What instruction should the nurse provide to prepare the client for the procedure?
- A. Drink clear liquids for 24 hours before the procedure
- B. Take a laxative the morning of the procedure
- C. Eat a light meal before the procedure
- D. Avoid drinking fluids for 4 hours before the procedure
Correct answer: A
Rationale: The correct instruction for preparing a client for a colonoscopy is to drink clear liquids for 24 hours before the procedure. This step helps to ensure the bowel is adequately cleared for the colonoscopy, allowing for better visualization and examination of the colon.
2. A postoperative client has three different PRN analgesics prescribed for varying levels of pain. The nurse inadvertently administers a dose that is not within the prescribed parameters. What action should the nurse take first?
- A. Assess for side effects of the medication.
- B. Document the client’s responses.
- C. Complete a medication error report.
- D. Determine if the pain was relieved.
Correct answer: A
Rationale: In the scenario where a nurse administers a medication outside the prescribed parameters, the immediate action should be to assess the client for any potential side effects of the medication. This is crucial to ensure the client's safety and well-being. By promptly assessing for side effects, the nurse can address any adverse reactions promptly and provide necessary interventions. Once the client's safety is ensured, documenting the client's responses, completing a medication error report, and assessing pain relief can follow as part of the broader response to the medication error. Choice B is not the first priority because the immediate concern is the potential harm from the incorrect dose. Choice C is also important but comes after ensuring the client's safety. Choice D focuses on the outcome rather than the immediate need to address any side effects of the medication.
3. The healthcare provider plans to administer diazepam, 4 mg IV push, to a client with severe anxiety. How many milliliters should the healthcare provider administer? (Round to the nearest tenth.)
- A. 0.2 mL
- B. 0.8 mL
- C. 1.25 mL
- D. 2.0 mL
Correct answer: B
Rationale: To calculate the volume to administer, use the formula (1 mL × 4 mg) / 5 mg = 0.8 mL. The healthcare provider should administer 0.8 mL of diazepam for a dosage of 4 mg IV push. Choice A is incorrect because it results from an incorrect calculation. Choices C and D are incorrect as they do not align with the correct calculation based on the provided dosage.
4. During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?
- A. Between the vaginal orifice and the anus.
- B. Between the clitoris and the vaginal orifice.
- C. Just above the clitoris.
- D. Within the vaginal canal.
Correct answer: B
Rationale: The correct location of the urethral meatus in females is between the clitoris and the vaginal orifice. When performing a urethral catheterization, it is crucial to identify this anatomical landmark for correct insertion of the catheter. Choice A is incorrect as the urethral meatus is not located between the vaginal orifice and the anus. Choice C is incorrect as the urethral meatus is not located just above the clitoris. Choice D is incorrect as the urethral meatus is not within the vaginal canal.
5. 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.
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