HESI Fundamentals Exam

Correct Answer: A

Rationale: The correct answer is A. Taking warfarin at the same time every day is essential to maintain a consistent blood level of the medication. This statement indicates that the client understands the teaching about the importance of consistency in medication timing. Choice B, regarding using a soft-bristled toothbrush, is not directly related to warfarin therapy and does not assess the client's understanding of warfarin administration. Choice C suggesting taking warfarin at bedtime is incorrect; it is generally recommended to take warfarin at the same time each day to avoid variations in drug levels. Choice D about avoiding foods high in vitamin K is relevant as vitamin K can interfere with warfarin's anticoagulant effects. However, it is not the best indicator of understanding the teaching on medication timing, which is crucial for warfarin efficacy.

Correct Answer: B

Rationale: The most important action to prevent infection in a client with an indwelling urinary catheter is to ensure the catheter tubing is free of kinks. This action helps prevent obstruction, ensures proper drainage, and reduces the risk of infection. Changing the catheter every 72 hours is not necessary unless clinically indicated and may introduce unnecessary risk. Cleaning the perineal area with antiseptic solution daily is important for general hygiene but not the most critical action for catheter-related infection prevention. Irrigating the catheter with normal saline every shift is not a routine nursing intervention for catheter care and may increase the risk of introducing pathogens.

Correct Answer: B

Rationale: The correct answer is B. Asking the client if they want to schedule prayer times during the day demonstrates respect and consideration for Islamic practices. Providing halal options (choice A) is important for dietary requirements in Islam, but it may not address the client's spiritual needs. Avoiding discussing care in front of the client's family (choice C) is not directly linked to Islamic practices and may not necessarily enhance cultural responsiveness. Offering daily communion (choice D) is associated with Christian religious practices, not Islamic practices, and may not meet the client's religious needs.

Correct Answer: A

Rationale: Using soft blankets to secure to the side rails provides better protection during a seizure as they are more secure and less likely to shift compared to pillows. This action helps prevent injury to the client by minimizing the risk of falling or hitting the side rails during a seizure. Choices B and C do not address the issue of using more secure materials. Choice D is inappropriate as it is important for the nurse to ensure the safety and well-being of the client by using the most appropriate protective measures.

Correct Answer: A

Rationale: A pericardial friction rub is characterized by a scratching sound that occurs during both systole and diastole. It becomes more distinct when the client is sitting up and leaning forward. This indicates an inflammation of the pericardial sac rubbing against the layers of the heart. Heart murmurs (choice B) are abnormal heart sounds caused by turbulent blood flow, not by friction like in a pericardial rub. S3 and S4 heart sounds (choices C and D) are additional heart sounds related to abnormal ventricular filling, not to pericardial friction rubs.