HESI Fundamentals Quizlet

Questions 54

HESI RN

HESI RN Test Bank

HESI Fundamentals Quizlet Questions

Question 1 of 5

A client who is a Jehovah's Witness is admitted to the nursing unit. Which concern should the nurse have for planning care in terms of the client's beliefs?

Correct Answer: B

Rationale: Blood transfusions are forbidden in the Jehovah's Witness religion. Judaism prohibits autopsy. Buddhism forbids the use of alcohol and drugs. Many of these sects are vegetarian, but the direct impact on nursing care is the prohibition of blood transfusions.

Question 2 of 5

When preparing to insert an indwelling urinary catheter, the nurse applies sterile gloves and then tests the catheter balloon for patency. What action should the nurse implement next?

Correct Answer: D

Rationale: After testing the catheter balloon for patency, the nurse should proceed to apply a sterile lubricant to the end of the catheter. This lubrication helps facilitate the insertion of the catheter smoothly. Placing a sterile drape under the client's buttocks should have been done prior to this step. Discarding the gloves and applying new sterile gloves is not necessary at this point in the procedure. Instructing the client to inhale and exhale slowly is not part of the immediate steps for inserting an indwelling urinary catheter.

Question 3 of 5

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) is receiving oxygen via nasal cannula at 4 liters per minute. Which assessment finding indicates a need for immediate action?

Correct Answer: C

Rationale: A report of shortness of breath (C) indicates that the client is not tolerating the oxygen therapy well and may need an adjustment. Shortness of breath is a critical symptom in a client with COPD, as it signifies potential respiratory distress. A respiratory rate of 14 (A), oxygen saturation of 92% (B), and respiratory rate of 24 (D) are not as immediately concerning as they may still fall within acceptable ranges for a client with COPD.

Question 4 of 5

When assessing a client with a nursing diagnosis of fluid volume deficit, the nurse notes that the client's skin over the sternum 'tents' when gently pinched. Which action should the nurse implement?

Correct Answer: C

Rationale: When the nurse observes that the client's skin over the sternum 'tents' when gently pinched, it is a classic sign of fluid volume deficit. The appropriate action for the nurse in this situation is to continue the planned nursing interventions aimed at restoring the client's fluid volume. This finding reinforces the need to address the fluid deficit and support the client's recovery.

Question 5 of 5

The healthcare provider is assessing the nutritional status of several clients. Which client has the greatest nutritional need for additional intake of protein?

Correct Answer: B

Rationale: A lactating woman (B) has the greatest need for additional protein intake. Lactation increases the metabolic demands for protein to support milk production, making it essential for the mother to have a higher protein intake. While clients in choices A, C, and D also require protein for various reasons, they do not have the same increased protein demands as a lactating woman.

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