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. A male healthcare provider is assigned to care for a female Muslim client. When the provider offers to bathe the client, the client requests that a female healthcare provider perform this task. How should the male healthcare provider respond?
- A. May I ask a female colleague to help you with your personal hygiene?
- B. I will ask one of the female healthcare providers to bathe you.
- C. A staff member on the next shift will help you.
- D. I will keep you draped and hand you the supplies as you need them.
Correct answer: B
Rationale: The most culturally sensitive response is for the male healthcare provider to ask one of the female healthcare providers to bathe the client. This approach respects the client's cultural and spiritual preferences by ensuring that their modesty and beliefs are honored during the care process. Choice A is incorrect as it puts the responsibility on the client to seek help, while the provider should take the initiative to arrange for appropriate care. Choice C is incorrect as it delays the assistance unnecessarily. Choice D, although helpful in maintaining modesty, does not address the client's request for a female healthcare provider to perform the task.
3. An older client who had abdominal surgery 3 days earlier was given a barbiturate for sleep and is now requesting to go to the bathroom. Which action should the nurse implement?
- A. Assist the client to walk to the bathroom and do not leave the client alone.
- B. Request that the UAP assist the client onto a bedpan.
- C. Ask if the client needs to have a bowel movement or void.
- D. Assess the client's bladder to determine if the client needs to urinate.
Correct answer: A
Rationale: Barbiturates cause central nervous system (CNS) depression, increasing the risk of falls. It is crucial for the nurse to assist the client to the bathroom to prevent potential injuries. Leaving the client alone may lead to accidents due to the effects of the medication. Monitoring and supporting the client during this activity is essential for ensuring safety and preventing falls.
4. When making the bed of a client who needs a bed cradle, which action should the nurse include?
- A. Teach the client to call for help before getting out of bed.
- B. Keep both the upper and lower side rails in a raised position.
- C. Keep the bed in the lowest position while changing the sheets.
- D. Drape the top sheet and covers loosely over the bed cradle.
Correct answer: D
Rationale: A bed cradle is used to keep the top bedclothes off the client, so the nurse should drape the top sheet and covers loosely over the cradle. This helps in maintaining the proper positioning and function of the bed cradle to ensure the client's comfort and safety during bed making.
5. The daughter of an older woman who became depressed following the death of her husband asks, 'My mother was always well-adjusted until my father died. Will she tend to be sick from now on?' Which response is best for the nurse to provide?
- A. She is almost sure to be less able to adapt than before.
- B. It's highly likely that she will recover and return to her pre-illness state.
- C. If you can interest her in something besides religion, it will help her stay well.
- D. Cultural strains contribute to each woman's tendencies for recurrences of depression.
Correct answer: B
Rationale: The successful resolution of a developmental crisis in the later years involves acceptance and adaptation, and the daughter should be reassured that recovery is likely.
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