a nurse observes a student nurse taking a copy of a clients medication administration record when questioned the student states another student is sch
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Nursing Elites

HESI RN

HESI Fundamentals Practice Exam

1. When a student nurse is caught taking a copy of a client's medication administration record to help a friend prepare for the next day's clinical, what should the nurse respond first?

Correct answer: D

Rationale: The correct response when a student nurse is caught taking a copy of a client's medication administration record is to explain that the records are hospital property and cannot be removed. It is essential to educate the student about the confidentiality and security of patient information, emphasizing that even with the client's consent, such actions are unacceptable. Option A is not the immediate action needed, as addressing the student directly should come first. Option B involves notifying another party before addressing the student directly. Option C is incorrect because even if the client gave permission, patient records are confidential and cannot be shared without authorization.

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?

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. How should the nurse prepare the body of a deceased adult for transfer to the mortuary?

Correct answer: B

Rationale: When preparing the body of a deceased adult for transfer to the mortuary, it is essential to bathe the body and place identification tags on it. This process ensures proper identification and respectful care of the deceased individual.

4. An unlicensed assistive personnel (UAP) places a client in a left lateral position prior to administering a soap suds enema. Which instruction should the nurse provide the UAP?

Correct answer: C

Rationale: The correct position for administering a soap suds enema is the Sims' position, not the left lateral position. The Sims' position allows the enema solution to follow the anatomical course of the intestines and provides the best overall results. By repositioning the client in the Sims' position, the weight is distributed to the anterior ilium, facilitating the enema administration process.

5. The healthcare provider is caring for a client who is experiencing fluid volume deficit (dehydration). Which intervention should the healthcare provider implement to assess the effectiveness of fluid replacement therapy?

Correct answer: A

Rationale: Monitoring daily weights is an accurate method to assess the effectiveness of fluid replacement therapy because changes in weight reflect changes in fluid balance. Fluid volume deficit can be objectively evaluated by monitoring daily weights as it provides a more precise measurement of fluid status over time. Assessing skin turgor (choice B) is subjective and may not provide as accurate or measurable data as monitoring daily weights. Evaluating blood pressure trends (choice C) can give information about circulatory status but may not directly reflect fluid volume status. Checking urine specific gravity (choice D) can indicate the concentration of urine but does not provide a comprehensive assessment of overall fluid balance like monitoring daily weights does.

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