the nurse is conducting an initial admission assessment for a woman who is mexican american and who is scheduled to deliver a baby by c section in the
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Nursing Elites

HESI RN

HESI Fundamentals

1. The healthcare provider is conducting an initial admission assessment for a woman who is Mexican-American and who is scheduled to deliver a baby by C-section in the next 24 hours. What should the healthcare provider include in the assessment?

Correct answer: D

Rationale: When caring for patients from diverse cultural backgrounds, it is essential to respect and consider their cultural norms and practices while providing healthcare. Understanding and incorporating cultural beliefs and values can enhance the quality of care and improve patient outcomes.

2. The client is being taught how to perform active range of motion (ROM) exercises. To exercise the hinge joints, which action should the client be instructed to perform?

Correct answer: B

Rationale: Hinge joints, like the elbow, primarily allow movement in one direction, in this case, bending the arm. The correct action to exercise hinge joints is to bend the arm by flexing the ulnar to the humerus. This movement specifically targets the hinge joint and promotes its range of motion. Choices A, C, and D involve movements that do not specifically target hinge joints. Tilt the pelvis involves the ball-and-socket joints of the hip, turning the head involves the pivot joint of the neck, and extending the arm and rotating it in circles involve multiple joints including ball-and-socket and pivot joints.

3. A client with chronic kidney disease is receiving peritoneal dialysis. Which assessment finding should the nurse report to the healthcare provider immediately?

Correct answer: B

Rationale: Cloudy peritoneal effluent (B) is a sign of infection and should be reported to the healthcare provider immediately. It indicates the presence of peritonitis, a severe complication that requires prompt intervention. Weight gain (A) may indicate fluid overload but is not as urgent as a potential infection. Elevated blood pressure (C) is a common finding in clients with kidney disease and needs monitoring but does not require immediate reporting. Clear and pale yellow effluent (D) is a normal finding and does not raise immediate concerns.

4. An older adult who recently began self-administration of insulin calls the nurse daily to review the steps that should be taken when giving an injection. The nurse has assessed the client's skills during two previous office visits and knows that the client is capable of giving the daily injection. Which response by the nurse is likely to be most helpful in encouraging the client to assume total responsibility for the daily injections?

Correct answer: C

Rationale: Choice C is the correct answer because focusing on the client's demonstrated ability to self-administer the injection is likely to reinforce his level of competence without sounding punitive. By acknowledging the client's correct performance during the self-injection, the nurse can boost the client's confidence, encouraging him to assume total responsibility for the daily injections. Choices A, B, and D do not directly highlight the client's competence in self-administration, which may not be as effective in promoting independent self-care.

5. In taking a client's history, the nurse asks about the stool characteristics. Which description should the nurse report to the health care provider as soon as possible?

Correct answer: A

Rationale: The correct answer is A: Daily black, sticky stool. Black sticky stool (melena) is a sign of gastrointestinal bleeding and should be reported to the health care provider promptly. This finding indicates the presence of digested blood in the stool. Choices B, C, and D describe variations of normal stool color and consistency, which do not raise immediate concerns related to gastrointestinal bleeding.

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