HESI RN
HESI Fundamentals
1. A healthcare professional is teaching a new colleague about the correct administration of subcutaneous (subQ) injections. Which instruction should the healthcare professional include?
- A. Insert the needle at a 90-degree angle for subQ injections
- B. Aspirate for blood return before injecting the medication
- C. Pinch the skin before inserting the needle
- D. Massage the site after administering the injection
Correct answer: C
Rationale: Pinching the skin before inserting the needle is essential in elevating the subcutaneous tissue away from the muscle. This technique ensures that the medication is administered into the correct tissue layer, promoting proper absorption and decreasing the risk of injecting into muscle tissue.
2. The nursing staff in the cardiovascular intensive care unit is creating a continuous quality improvement project on social media that addresses coronary artery disease (CAD). Which action should the nurse implement to protect client privacy?
- A. Remove identifying information of the clients who participated
- B. Recall that authored content may be legally discoverable
- C. Share material from credible, peer-reviewed sources only
- D. Respect all copyright laws when adding website content
Correct answer: A
Rationale: To protect client privacy on social media, it is essential to remove any identifying information of clients who participated in the project. This ensures that sensitive information is not disclosed without consent and maintains confidentiality. Choice B is incorrect because while authored content may be legally discoverable, it does not directly relate to protecting client privacy on social media. Choice C is incorrect as it pertains to the credibility of sources, not client privacy. Choice D is also incorrect as it focuses on copyright laws rather than client privacy protection.
3. 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.
4. A female client’s significant other has been at her bedside providing reassurances and support for the past 3 days, as desired by the client. The client’s estranged husband arrives and demands that the significant other not be allowed to visit or be given condition updates. Which intervention should the nurse implement?
- A. Obtain a prescription from the healthcare provider regarding visitation privileges
- B. Request a consultation with the ethics committee for resolution of the situation
- C. Encourage the client to speak with her husband regarding his disruptive behavior
- D. Communicate the client’s wishes to all members of the multidisciplinary team
Correct answer: B
Rationale: In a situation where a client's estranged husband demands to restrict the visitation of the significant other, it is essential to prioritize the client's wishes while addressing the conflict. Requesting a consultation with the ethics committee is appropriate as it allows for a comprehensive and impartial resolution, ensuring the client's autonomy and well-being are upheld. Option A is incorrect because visitation privileges are not solely determined by a healthcare provider's prescription in this scenario. Option C may not be appropriate as it puts the client in a potentially uncomfortable or unsafe position. Option D, while important, does not directly address the conflict between the estranged husband and the significant other.
5. When a male client mentions his foot is hurting while watching TV with his wife, how should the nurse respond?
- A. Ask him to rate his pain on a scale of 1 to 10.
- B. Encourage him to wait until bedtime for the pill to help him sleep.
- C. Attend to an acutely ill client's needs first as the client is laughing.
- D. Instruct him in the use of deep breathing exercises for pain control.
Correct answer: A
Rationale: The correct response is to ask the client to rate his pain on a scale of 1 to 10. This helps the nurse assess the intensity of the pain and determine the appropriate pain medication. Encouraging him to wait or attend to another client's needs first are incorrect because pain management should be addressed promptly. Instructing on deep breathing exercises may be helpful but is not the initial step in addressing acute pain.
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