HESI RN
HESI Quizlet Fundamentals
1. 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.
2. A client has a nursing diagnosis of Altered sleep patterns related to nocturia. Which client instruction is important for the nurse to provide?
- A. Decrease intake of fluids after the evening meal.
- B. Drink a glass of cranberry juice every day.
- C. Drink a glass of warm decaffeinated beverage at bedtime.
- D. Consult the healthcare provider about a sleeping pill.
Correct answer: A
Rationale: The correct instruction for the nurse to provide is to advise the client to decrease intake of fluids after the evening meal. By reducing fluid intake before bedtime, the client can minimize the need to void during the night, which can help improve sleep patterns affected by nocturia. Choices B, C, and D are incorrect. Drinking cranberry juice or warm decaffeinated beverage at bedtime may increase fluid intake, exacerbating the nocturia issue. Consulting the healthcare provider about a sleeping pill should not be the first intervention, as it is important to try non-pharmacological approaches first.
3. A client with rheumatoid arthritis is experiencing chronic pain in both hands and wrists. Which information about the client is most important for the nurse to obtain when planning care?
- A. Amount of support provided by family members
- B. Measurement of pain using a scale of 0 to 10
- C. The ability to perform ADLs
- D. Nonverbal behaviors exhibited when pain occurs
Correct answer: C
Rationale: Assessing the client's ability to perform activities of daily living (ADLs) is crucial in planning care for someone with chronic pain. Understanding the client's functional status helps the nurse tailor interventions to promote independence and enhance quality of life. It provides valuable insight into the impact of pain on daily activities and guides the development of a comprehensive care plan to address the client's specific needs. While family support, pain measurement, and nonverbal behaviors are important aspects to consider in caring for a client with chronic pain, the ability to perform ADLs directly reflects the client's independence and quality of life, making it the most crucial information to obtain.
4. The health care provider has changed a client's prescription from the PO to the IV route of administration. The nurse should anticipate which change in the pharmacokinetic properties of the medication?
- A. The client will experience increased tolerance to the drug's effects and may need a higher dose.
- B. The onset of action of the drug will occur more rapidly, resulting in a more rapid effect.
- C. The medication will be more highly protein-bound, increasing the duration of action.
- D. The therapeutic index will be increased, placing the client at greater risk for toxicity.
Correct answer: B
Rationale: When a medication is administered via the IV route, the absorptive process is bypassed, leading to a more rapid onset of action. This results in a faster effect of the drug. Choice A is incorrect because changing the route of administration does not necessarily lead to increased tolerance or the need for a higher dose. Choice C is incorrect as changing the route of administration does not directly affect the protein binding of a medication. Choice D is incorrect because increasing the therapeutic index would actually reduce the risk of toxicity, not increase it.
5. The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?
- A. Document that the client responds to a painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the healthcare provider.
Correct answer: A
Rationale: The client's response to a painful stimulus indicates a purposeful reaction, which should be accurately documented as per the assessment findings. This documentation is essential for ongoing monitoring and communication of the client's condition to the healthcare team.
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