HESI RN
HESI Fundamentals
1. What action should be taken when adding sterile liquids to a sterile field?
- A. Use an expired sterile liquid if the bottle is sealed and unopened.
- B. Consider the sterile field contaminated if it becomes wet during the procedure.
- C. Remove the container cap and place it with the inside facing up on the sterile field.
- D. Hold the container low and pour the solution into a receptacle at the front of the sterile field.
Correct answer: B
Rationale: If a sterile field becomes wet or damp during a procedure, it is considered contaminated as moisture can allow organisms to wick from the surface and compromise the sterility of the field. It is essential to maintain the integrity of the sterile field to prevent infections and ensure patient safety.
2. What action should the nurse implement to prepare a client for the potential side effects of a newly prescribed medication?
- A. Assess the client for health alterations that may be impacted by the effects of the medication
- B. Teach the client how to administer the medication to promote the best absorption
- C. Administer a half dose and observe the client for side effects before administering a full dosage
- D. Encourage the client to drink plenty of fluids to promote effective drug distribution
Correct answer: A
Rationale: Before initiating a new medication, the nurse should conduct a thorough assessment of the client to identify any pre-existing health conditions or risk factors that could be affected by the medication. This assessment helps in establishing a baseline for monitoring potential side effects and determining the medication's appropriateness for the client. Choice B is incorrect as teaching the client how to administer the medication does not directly address preparing for potential side effects. Choice C is incorrect because administering a half dose without a proper assessment could be unsafe. Choice D is incorrect as encouraging fluid intake is not directly related to preparing for potential side effects of a medication.
3. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid eating green leafy vegetables.
- B. I should wear loose-fitting clothes to avoid pressure on my legs.
- C. I should avoid prolonged sitting or standing.
- D. I should continue taking my over-the-counter herbal supplements.
Correct answer: D
Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.
4. 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.
5. Which client is most likely to be at risk for spiritual distress?
- A. Roman Catholic woman considering an abortion
- B. Jewish man considering hospice care for his wife
- C. Seventh-day Adventist in need of a blood transfusion
- D. Muslim man in need of a total knee replacement
Correct answer: A
Rationale: The correct answer is A. In Roman Catholicism, abortion is strictly prohibited, so a Roman Catholic woman considering this procedure may experience spiritual distress due to conflicts with her religious beliefs. This conflict can lead to emotional and psychological turmoil, affecting her spiritual well-being. It is essential for healthcare providers to recognize and address such conflicts with sensitivity and understanding to provide holistic care.
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