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 UAP is positioning a newly admitted client with a seizure disorder in a supine position. The UAP is placing soft pillows along the side rails. What action should the nurse take?
- A. Instruct the UAP to obtain soft blankets to secure to the side rails instead of pillows
- B. Ensure that the UAP has placed pillows effectively to protect the client
- C. Ask the UAP to use some pillows to prop the client in a side-lying position
- D. Assume responsibility for placing the pillows while the UAP completes another task
Correct answer: A
Rationale: To prevent the risk of suffocation, soft blankets are preferred over pillows for padding side rails in clients with seizure disorders. Pillows can pose a suffocation hazard, especially during a seizure episode when the client's movements may be uncontrolled. Instructing the UAP to use soft blankets instead of pillows is crucial for ensuring the client's safety. Choice B is incorrect because pillows can be hazardous during a seizure. Choice C is incorrect as side-lying position may not be appropriate for a client with a seizure disorder. Choice D is incorrect as it does not address the safety concern related to using pillows.
3. The healthcare professional is preparing to administer 10 mL of liquid potassium chloride through a feeding tube, followed by 10 mL of liquid acetaminophen. Which action should the healthcare professional include in this procedure?
- A. Dilute each of the medications with sterile water prior to administration.
- B. Mix the medications in one syringe before opening the feeding tube.
- C. Administer water between the doses of the two liquid medications.
- D. Withdraw any fluid from the tube before instilling each medication.
Correct answer: C
Rationale: To maintain patency and ensure proper medication delivery, water should be instilled into the feeding tube between administering the two medications. This helps prevent clogging of the tube and ensures that both medications are delivered effectively without interference from remnants of the previous medication. Diluting the medications with sterile water before administration (choice A) is unnecessary and may alter the medication concentration. Mixing the medications in one syringe (choice B) could lead to interactions or chemical reactions between the medications. Withdrawing fluid from the tube before instilling each medication (choice D) is not required and may increase the risk of tube displacement or misplacement.
4. The nurse is providing discharge teaching to a client with a new diagnosis of osteoporosis. Which instruction should the nurse include?
- A. Increase dietary intake of calcium-rich foods.
- B. Avoid activities that increase the risk of falls.
- C. Avoid prolonged exposure to sunlight.
- D. Increase intake of vitamin D supplements.
Correct answer: B
Rationale: Avoiding activities that increase the risk of falls (B) is the most crucial instruction for a client with osteoporosis to prevent fractures. Osteoporosis weakens bones, making them more susceptible to fractures from falls. While increasing calcium intake (A) is important for bone health, avoiding falls takes precedence to prevent immediate harm. Avoiding prolonged exposure to sunlight (C) is not directly related to osteoporosis management. Increasing vitamin D supplements (D) is beneficial for bone health, but fall prevention is more critical in this scenario.
5. After abdominal surgery, an adult is now alert and oriented. What position is most appropriate for the client?
- A. Semi-Fowler's
- B. Prone
- C. Supine
- D. Sim's
Correct answer: A
Rationale: The most appropriate position for a client following abdominal surgery is Semi-Fowler's. This position promotes greater thoracic expansion and reduces pressure on the suture line, aiding in respiratory function and preventing strain on the incision site. Choices B, C, and D are incorrect. Prone position (Choice B) would not be suitable after abdominal surgery as it can put pressure on the abdomen. Supine position (Choice C) may cause discomfort and strain on the incision area. Sim's position (Choice D) is primarily used for rectal exams and enemas, which are unrelated to the needs post-abdominal surgery.
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