HESI RN
HESI Fundamentals
1. A client with a diagnosis of coronary artery disease is receiving atorvastatin (Lipitor). Which laboratory test should the nurse monitor to evaluate the effectiveness of this medication?
- A. Complete blood count (CBC)
- B. Serum potassium level
- C. Liver function tests (LFTs)
- D. Serum cholesterol level
Correct answer: C
Rationale: To evaluate the effectiveness of atorvastatin (Lipitor), the nurse should monitor liver function tests (LFTs) (C) because this medication can impact liver function. Complete blood count (CBC) (A), serum potassium level (B), and serum cholesterol level (D) are not directly indicative of the medication's effectiveness in managing coronary artery disease.
2. The client has a chest tube. What is the most important action for the nurse to take?
- A. Ensure the chest tube remains unclamped at all times.
- B. Empty the chest tube every 2 hours.
- C. Keep the drainage system below the level of the chest.
- D. Assess for subcutaneous emphysema.
Correct answer: C
Rationale: Keeping the drainage system below the level of the chest (C) is crucial to ensure proper drainage and prevent backflow of air or fluid into the chest cavity. This position helps maintain the integrity of the closed drainage system. Ensuring the chest tube remains unclamped at all times (A) allows for continuous drainage. Emptying the chest tube (B) should be done as needed, not routinely every 2 hours. Assessing for subcutaneous emphysema (D) is important but not the most critical action in this scenario.
3. The nurse is preparing a client for surgery. What action is most important for the nurse to take?
- A. Ensure that the client signs the consent form.
- B. Review the client's allergies with the surgical team.
- C. Confirm the client's identity using two identifiers.
- D. Verify that the surgical site is marked.
Correct answer: A
Rationale: Ensuring that the client signs the consent form (A) is the most crucial action before surgery. The consent form is legally and ethically necessary for the procedure to proceed. While reviewing allergies (B), confirming identity (C), and verifying the surgical site (D) are essential steps, obtaining the client's informed consent takes precedence to protect the client's rights and ensure a safe surgical experience.
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. The healthcare professional in the emergency department observes a colleague viewing the electronic health record (EHR) of a client who holds an elected position in the community. The client is not a part of the colleague’s assignment. Which action should the healthcare professional implement?
- A. Communicate the colleague’s actions to the unit charge nurse
- B. Send an email to facility administration reporting the action
- C. Write an anonymous complaint to a professional website
- D. Post a comment about the action on a staff discussion board
Correct answer: A
Rationale: Observing a colleague accessing a patient's EHR without a legitimate reason is a violation of HIPAA, which protects patient confidentiality. The appropriate action in this scenario is to communicate the colleague’s actions to the unit charge nurse immediately. The charge nurse can then address the issue internally and ensure that patient privacy is maintained. Reporting the incident through the appropriate channels within the healthcare facility is the most effective and professional way to handle such breaches of patient confidentiality. Choices B, C, and D are incorrect because they do not involve addressing the issue internally within the healthcare facility. Reporting such incidents internally is essential to ensure that patient privacy is protected, and the matter is handled appropriately by healthcare authorities.
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