HESI RN
HESI Fundamentals
1. When culturing a wound, the nurse should obtain the sample from which part of the wound?
- A. The outer edges of the wound.
- B. All necrotic sections of the wound.
- C. Areas containing purulent or pooled exudates.
- D. Any particularly painful area of the wound.
Correct answer: C
Rationale: To collect a wound culture, the nurse should first clean the wound to remove skin flora and then insert a sterile swab from a culturette tube into the wound secretions.
2. Which nonverbal action should be implemented to demonstrate active listening?
- A. Sit facing the individual.
- B. Cross arms and legs.
- C. Avoid eye contact.
- D. Lean back in the chair.
Correct answer: A
Rationale: To demonstrate active listening effectively, it is essential to display open and engaging body language. Sitting facing the individual helps convey attentiveness and a willingness to listen. Maintaining eye contact further enhances the connection and shows respect and interest in the conversation. Crossing arms and legs can create a barrier and signal defensiveness or disinterest. Avoiding eye contact may suggest a lack of engagement or attentiveness. Leaning back in the chair can indicate relaxation but might be perceived as disengagement. Therefore, the most appropriate nonverbal action to demonstrate active listening is to sit facing the individual and maintain eye contact.
3. After a needle stick occurs while removing the cap from a sterile needle, what action should the individual take?
- A. Complete an incident report.
- B. Select another sterile needle.
- C. Disinfect the needle with an alcohol swab.
- D. Notify the supervisor immediately.
Correct answer: B
Rationale: In the scenario described, the correct action after a needle stick injury is to discard the contaminated needle safely and choose a new sterile needle to continue the procedure. This step helps prevent potential transmission of infections and ensures the safety of both the individual and the patient. Disinfecting the needle with an alcohol swab is not adequate to address the risk of infection transmission. While completing an incident report and notifying the supervisor are important, the immediate action should be to replace the contaminated needle with a new sterile one to prevent any potential harm.
4. UAP has lowered the head of the bed to change the linens for a client who is bedbound with a foley catheter and enteral tube feeds. Which change from the client warrants the most immediate intervention by the nurse?
- A. A feeding is infusing at 40 mL/hr through an enteral feeding tube
- B. The urine meter attached to the urinary drainage bag is completely full
- C. There is a large dependent loop in the client’s urinary drainage tubing
- D. Purulent drainage is present around the insertion site of the feeding tube
Correct answer: D
Rationale: Purulent drainage indicates infection at the insertion site, which requires immediate attention to prevent complications.
5. The client with cholecystitis is being instructed on dietary choices. Which meal best meets the dietary needs of this client?
- A. Steak, baked beans, and a salad
- B. Broiled fish, green beans, and an apple
- C. Pork chops, macaroni and cheese, and grapes
- D. Avocado salad, milk, and angel food cake
Correct answer: B
Rationale: Cholecystitis requires a low-fat diet to reduce stress on the gallbladder. The meal of broiled fish, green beans, and an apple aligns with this dietary recommendation by providing lean protein and low-fat, high-fiber foods that are easier for the body to digest, making it the most suitable choice for a client with cholecystitis.
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