HESI RN
HESI Fundamentals
1. While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client’s comfort level is increased when the nurse breaks eye contact to type notes into the record
- B. The interview process is enhanced with electronic documentation and allows the client to speak at a normal pace
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is a legal obligation of the examining nurse
Correct answer: C
Rationale: Choosing electronic documentation during an interview may hinder the nurse's ability to observe the client's nonverbal cues. Nonverbal communication, such as body language and facial expressions, plays a crucial role in understanding a client's feelings and needs. Focusing on entering data electronically may lead to missing important nonverbal cues that could provide valuable insights into the client's condition or emotions.
2. When faced with caring for a close friend in a professional setting, which action should the staff member take first?
- A. Notify the friend that all medical information will be kept confidential.
- B. Explain the relationship to the charge nurse and ask for reassignment.
- C. Approach the client and ask if the assignment is uncomfortable.
- D. Accept the assignment but protect the client's confidentiality.
Correct answer: B
Rationale: When faced with caring for a close friend in a professional setting, the staff member should first explain the relationship to the charge nurse and ask for reassignment. This is important to maintain professional boundaries, prevent conflicts of interest, and ensure that the care provided is unbiased and without compromising the friend's confidentiality. Choice A is incorrect because the priority should be on professional boundaries rather than informing the friend about confidentiality. Choice C is not appropriate as it puts the burden on the client to address any discomfort. Choice D is incorrect as accepting the assignment without addressing the potential conflict of interest could lead to compromised care.
3. 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.
4. A client with a diagnosis of deep vein thrombosis (DVT) is receiving anticoagulation therapy. Which statement by the client indicates a need for further teaching?
- A. I should avoid eating green leafy vegetables.
- B. I should wear loose-fitting clothes to avoid pressure on my legs.
- C. I should avoid prolonged sitting or standing.
- D. I should continue taking my over-the-counter herbal supplements.
Correct answer: D
Rationale: The statement 'I should continue taking my over-the-counter herbal supplements' (D) indicates a need for further teaching because some herbal supplements can interact with anticoagulants, increasing the risk of bleeding. It is crucial to inform healthcare providers about all medications, including herbal supplements, to prevent adverse interactions. The other statements reflect appropriate understanding of precautions related to DVT and anticoagulation therapy.
5. The healthcare provider who is preparing to give an adolescent client a prescribed antipsychotic medication notes that parental consent has not been obtained. Which action should the provider take?
- A. Review the chart for a signed consent for medication administration.
- B. Obtain parental consent before giving the medication.
- C. Do not give the medication and document the reason.
- D. Complete an incident report and notify the adolescent.
Correct answer: C
Rationale: The correct action is for the provider not to administer the medication and to document the reason. In the case of a minor, parental consent is required for medical treatment, including medication administration. It is important to follow legal and ethical guidelines to ensure the adolescent's well-being and rights are protected. Choice A is incorrect because simply reviewing the chart does not address the lack of parental consent. Choice B is incorrect as obtaining parental consent should be done before medication administration. Choice D is incorrect as notifying the adolescent is not the appropriate action in this situation, as parental consent is legally required for a minor's medical treatment.
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