HESI RN
HESI Fundamentals
1. When a client has suffered severe burns all over his body, the most effective method of monitoring the cardiovascular system is:
- A. Cuff blood pressure.
- B. Arterial pressure.
- C. Pulmonary artery pressure.
- D. Central venous pressure.
Correct answer: D
Rationale: Central venous pressure (CVP) monitoring is the most effective method to assess fluid status and the cardiovascular system in a client with severe burns. Severe burns can lead to significant fluid shifts and hemodynamic changes, making central venous pressure monitoring crucial for guiding fluid resuscitation and managing cardiovascular stability in these patients.
2. 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.
3. During a routine assessment, an obese 50-year-old female client expresses concern about her sexual relationship with her husband. Which is the best response by the nurse?
- A. Reassure the client that many obese individuals have concerns about sex.
- B. Remind the client that sexual relationships can be maintained regardless of weight.
- C. Determine the frequency of sexual intercourse.
- D. Ask the client to talk about specific concerns.
Correct answer: D
Rationale: The best response for the nurse is to ask the client to talk about specific concerns. This approach provides an opportunity for the client to express her worries openly, allowing the nurse to gather more detailed information for a comprehensive assessment and to address the client's concerns effectively.
4. During a urethral catheterization on a female, where would the healthcare provider observe the urethral meatus after separating the labia?
- A. Between the vaginal orifice and the anus.
- B. Between the clitoris and the vaginal orifice.
- C. Just above the clitoris.
- D. Within the vaginal canal.
Correct answer: B
Rationale: The correct location of the urethral meatus in females is between the clitoris and the vaginal orifice. When performing a urethral catheterization, it is crucial to identify this anatomical landmark for correct insertion of the catheter. Choice A is incorrect as the urethral meatus is not located between the vaginal orifice and the anus. Choice C is incorrect as the urethral meatus is not located just above the clitoris. Choice D is incorrect as the urethral meatus is not within the vaginal canal.
5. The father of an 11-year-old client reports to the nurse that the client has been 'wetting the bed' since the passing of his mother and is concerned. Which action is most important for the nurse to take?
- A. Reassure the father that it is normal for a child to wet the bed after a traumatic event
- B. Inform the father that nocturnal emissions are abnormal and his son is developmentally delayed
- C. Inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma
- D. Refer the father and the client to a psychologist
Correct answer: C
Rationale: Bedwetting after trauma, such as losing a parent, is common in children. The nurse should inform the father that it is crucial to let the son know that bedwetting is a normal response to trauma. Reassurance and understanding are essential in addressing the child's emotional needs during this difficult time. Choice A is incorrect as it focuses on puberty rather than trauma as the underlying cause. Choice B is incorrect as it provides inaccurate information about nocturnal emissions and developmental delay. Choice D is premature as the first step should be to provide education and support before considering a referral to a psychologist.
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