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. The healthcare provider plans to foster a therapeutic relationship with the patient utilizing therapeutic techniques of communication. It is most important that the provider:
- A. Work on establishing rapport with the patient.
- B. Use humor to lighten emotionally charged topics of discussion.
- C. Empathize with the patient when the patient shares sad feelings.
- D. Demonstrate respect when discussing emotionally charged topics.
Correct answer: D
Rationale: In fostering a therapeutic relationship, demonstrating respect is essential as it helps the patient feel valued and understood. Respectful communication contributes to building trust and a safe environment for open and honest discussions.
3. When caring for a client in hemorrhagic shock, how should the nurse position the client?
- A. Flat in bed with legs elevated.
- B. Flat in bed.
- C. Trendelenburg position.
- D. Semi-Fowler's position.
Correct answer: A
Rationale: When caring for a client in hemorrhagic shock, the nurse should position the client flat in bed with legs elevated. Elevating the legs helps increase venous return to the heart, aiding in the management of hemorrhagic shock by maintaining perfusion to vital organs.
4. The healthcare professional is obtaining a lie-sit-stand blood pressure reading on a client. Which action is most important for the healthcare professional to implement?
- A. Stay with the client while the client is standing.
- B. Record the findings on the graphic sheet in the chart.
- C. Keep the blood pressure cuff on the same arm.
- D. Record changes in the client's pulse rate.
Correct answer: A
Rationale: In obtaining a lie-sit-stand blood pressure reading, it is crucial for the healthcare professional to stay with the client while the client is standing. This action is the most important as it ensures client safety during the procedure. Recording findings, keeping the blood pressure cuff on the same arm, and monitoring pulse rate are all important tasks, but staying with the client while standing takes priority to prevent any potential falls or adverse events. By staying with the client, the healthcare professional can promptly address any signs of dizziness or instability, ensuring a safe environment for the client throughout the procedure.
5. The client is being taught how to self-administer a subcutaneous injection. To ensure sterility of the procedure, which subject is most important for the instructor to include in the teaching plan?
- A. Hand washing before preparing the injection.
- B. Technique for drawing medication from a vial.
- C. Selection and rotation of injection sites.
- D. Proper disposal of injection equipment.
Correct answer: B
Rationale: To maintain the sterility of the procedure, it is crucial to teach the client the correct technique for drawing medication from a vial. This ensures that the medication remains sterile during preparation and administration. While hand washing, injection site selection, and equipment disposal are important aspects of injection safety, the key focus should be on maintaining the sterility of the medication itself to prevent infections and ensure the effectiveness of the treatment.
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