HESI RN
HESI Quizlet Fundamentals
1. During a sterile procedure at a client's bedside, a healthcare provider contaminates a sterile glove and the sterile field. What is the best action for the nurse to implement?
- A. Report the incident to the supervisor for aseptic technique violation.
- B. Allow the completion of the procedure.
- C. Inquire about the contamination of the glove and sterile field.
- D. Identify the breach in surgical asepsis and provide a new set of sterile supplies.
Correct answer: D
Rationale: In the scenario where a healthcare provider contaminates a sterile glove and the sterile field during a procedure, it is crucial to identify any breach in surgical asepsis. Any potential contamination should be considered compromised, and the nurse must act promptly to maintain sterility by providing a fresh set of sterile supplies for the procedure to continue safely.
2. A high school senior is complaining of a persistent cough and admits to smoking 10 to 15 cigarettes daily for the past year. He is convinced that he is hopelessly addicted to tobacco since he tried unsuccessfully to quit smoking last week. Which intervention is best for the nurse to implement?
- A. Encourage the student to associate with non-smokers only while attempting to stop smoking.
- B. Tell the student that he is still young and should continue trying various smoking cessation methods.
- C. Describe cigarette smoking as a habit that requires a strong will to overcome its addictiveness.
- D. Provide the student with the latest research data describing the long-term effects of tobacco use.
Correct answer: A
Rationale: Adolescents are particularly influenced by peers, so associating with non-smokers may help the student quit smoking. By being surrounded by non-smokers, the student is less likely to feel pressured to smoke and may be encouraged to adopt healthier behaviors. This intervention leverages the power of social influence to support smoking cessation efforts and create a more conducive environment for the student to quit smoking. Choices B, C, and D do not address the social aspect of smoking behavior and the influence of peers on smoking habits, making them less effective interventions in this case.
3. The client is 5 feet from the bathroom door when he states, 'I feel faint.' Before the nurse can get the client to a chair, the client starts to fall. What is the priority action for the nurse to take?
- A. Check the client's carotid pulse.
- B. Encourage the client to get to the toilet.
- C. In a loud voice, call for help.
- D. Gently lower the client to the floor.
Correct answer: D
Rationale: The priority action for the nurse in this situation is to gently lower the client to the floor. This action helps prevent injury to both the client and the nurse. It is important to ensure a safe environment and protect the client from falling, as well as to maintain the nurse's own safety while providing care.
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 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.
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