HESI RN
HESI Fundamentals
1. When assisting a client from the bed to a chair, which procedure is best for the nurse to follow?
- A. Place the chair parallel to the bed, with its back toward the head of the bed, and assist the client in moving to the chair.
- B. With the nurse's feet spread apart and knees aligned with the client's knees, stand and pivot the client into the chair.
- C. Assist the client to a standing position by gently lifting upward underneath the axillae.
- D. Stand beside the client, place the client's arms around the nurse's neck, and gently move the client to the chair.
Correct answer: B
Rationale: Option B is the best procedure for the nurse to follow when assisting a client from the bed to a chair. This option emphasizes the correct positioning of the nurse with feet spread apart and knees aligned with the client's, providing a stable base of support. By standing and pivoting the client into the chair, the nurse can maintain control and stability, especially around the client's knees, ensuring a safe transfer.
2. During the suctioning of a tracheostomy tube, if the catheter appears to attach to the tracheal walls and creates a pulling sensation, what is the best action for the nurse to take?
- A. Release the suction by opening the vent.
- B. Continue suctioning to remove obstruction.
- C. Increase the pressure.
- D. Suction deeper.
Correct answer: A
Rationale: When the catheter of the suctioning device attaches to the tracheal walls, causing a pulling sensation, the nurse should release the suction by opening the vent. This action will alleviate the pulling sensation and prevent trauma to the delicate tracheal walls. Continuing suctioning or applying more pressure can lead to tissue damage and should be avoided. Suctioning deeper can increase the risk of injuring the patient's airway.
3. The healthcare provider is assessing several clients prior to surgery. Which factor in a client's history poses the greatest threat for complications to occur during surgery?
- A. Taking birth control pills for the past 2 years
- B. Taking anticoagulants for the past year
- C. Recently completing antibiotic therapy
- D. Having taken laxatives PRN for the last 6 months
Correct answer: B
Rationale: Anticoagulants increase the risk of bleeding during surgery, which can lead to complications such as excessive bleeding and difficulty in achieving hemostasis. This poses a significant threat during a surgical procedure where controlling bleeding is crucial for a successful outcome. The other options (A, C, D) are not as critical as anticoagulants in terms of posing a threat for complications during surgery. Birth control pills, recently completing antibiotic therapy, and using laxatives do not directly impact bleeding risks during surgery compared to anticoagulants.
4. The healthcare provider is teaching a client with hypertension about lifestyle modifications. Which instruction should the healthcare provider include?
- A. Limit sodium intake to 2,300 mg per day
- B. Engage in moderate exercise for 30 minutes daily
- C. Consume a diet high in saturated fats
- D. Avoid alcohol consumption completely
Correct answer: B
Rationale: Engaging in moderate exercise for 30 minutes daily is a crucial lifestyle modification for managing hypertension. Regular physical activity helps lower blood pressure, improve cardiovascular health, and overall well-being. It is recommended to engage in activities like brisk walking, cycling, or swimming to achieve these benefits. Choices A, C, and D are incorrect. Limiting sodium intake, avoiding a diet high in saturated fats, and reducing alcohol consumption are also important lifestyle modifications for hypertension management, but engaging in moderate exercise is the most appropriate initial instruction for this client.
5. While the nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia and reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?
- A. Instruct the client to repeat the medication plan
- B. Encourage the client to take a PRN antianxiety drug
- C. Provide written instructions that are easy to follow
- D. Include a family member in the teaching session
Correct answer: A
Rationale: In this situation, the most important action for the nurse to implement is to instruct the client to repeat the medication plan. By using the teach-back method, the nurse can ensure the client's understanding of the prescribed medications and address any concerns or anxieties the client may have. This approach promotes patient engagement, active participation, and retention of important information, ultimately enhancing medication adherence and safety.
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